Are Panoramic Images a Good Tool to Detect Calcified Carotid Atheroma? A Systematic Review

Simple Summary The goal of the present review is to investigate the reliability of panoramic dental images to detect calcified carotid atheroma. The findings of this systematic review exhibit that panoramic radiographs can be used for dental diagnosis and treatment planning, as well as to detect calcified carotid artery atheroma, so it can be a tool to prevent cardiovascular diseases. Abstract To investigate the reliability of panoramic dental images to detect calcified carotid atheroma, electronic databases (PubMed, IEEE/Xplore and Embase) were searched. Outcomes included cerebrovascular disease events, cardiovascular disease events, patient previous diseases, and combined endpoints. Risk of bias was evaluated using the Newcastle-Ottawa Scale. Hence, 15 studies were selected from 507 potential manuscripts. Five studies had a low risk of bias, while the remaining nine studies were found to have a moderate risk. Heterogeneous results were obtained but showed that patients with risk factors, such as obesity, diabetes mellitus, hypertension, and smoking, and with calcified carotid atheroma on panoramic images, have a higher prevalence than healthy patients. The evidence in the literature was found to be equivocal. However, the findings of this systematic review exhibit that panoramic radiographs can be used for dental diagnosis and treatment planning, as well as to detect calcified carotid artery atheroma.


Introduction
The disease of the arteries characterized by the deposition of fatty material on its wall, forming atheroma plaques, is called atherosclerosis. These plaques may suffer calcification and project themselves into the vessel lumen, determining blood flow change [1].
Atherosclerosis is a disease that postpones its clinical manifestations and sometimes has no clinical symptoms. Therefore, any method to diagnose atheroma plaques is very important [2,3] The most common images employed in daily dental practice are panoramic images. These kinds of images allow the professional to observe the area of the first cervical vertebrae, becoming an important tool to help in the early diagnosis of calcified atheroma in common carotid artery [1,4,5]. The calcified atheroma plaques can be detected in radiographies as irregular, circular, or heterogeneous radiopaque masses, unilateral or bilateral, which are usually located posterosuperiorly to the angle of mandible, approximately at the inferior margin of third cervical vertebra (between C3 and C4) near the hyoid bone [6].
The first to describe the presence of calcification by panoramic radiographs were Friedlander and Lande [7]. Several studies noted that by panoramic radiographs can be identified asymptomatic patients at risk for stroke [8,9].
The aim of the present review is to analyze the reliability of panoramic dental images to detect calcified carotid atheroma.

Materials and Methods
The present study employed the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-analyses) statement to conduct and report the results [10].

Inclusion Criteria
The inclusion criteria were full manuscripts, including conference proceedings, that reported: -Cohort and case-control studies evaluating the diseases associated with patients with carotid artery calcifications on panoramic dental radiographs.

Exclusion Criteria
The exclusion criteria were: -Systematic or literature reviews -No dental images application -Editorials, commentaries, and letters to the editor -Case reports, in vivo or cross-sectional studies that only report on the prevalence of disease. Studies in which the patient suffered the adverse event before the dental radiograph was acquired o Evaluated calcifications outside the carotid arteries in the neck There were no restrictions on the language or date of publication.

Search Strategy
An electronic search was performed in the following databases up until 15 September 2022: MEDLINE/PubMed, Institute of Electrical and Electronics Engineers (IEEE) Xplore, and ScienceDirect. The search strategy used is detailed in Table 1.

Study Selection and Items Collected
M.P.-P. and J.G.-V. performed the bibliographic search and selected the articles that fulfilled the inclusion criteria. Both authors collected all the data from the selected articles in duplicate and independently of each other. Disagreements between the two authors were reviewed using the full text by a third author (C.I.) to make the final decision. The references of the articles included in this study were manually reviewed.
The following items were collected: authors, year, participant characteristics (sample size, gender, age), participants' medical records, results of the study, and their main findings.

Study Quality Assessment
Modified Newcastle-Ottawa Scale was employed to evaluate the risk of bias of each study included in the present review [11]. Assessments were based on selection of study and control groups (4 stars), comparability of the groups (2 stars) and exposure, including outcome measurement and follow-up for at least 5 years (3 stars). The maximum possible quality score is 9 stars. Studies that scored 7-9 stars were considered as low risk of bias, 4-6 stars were considered as moderate risk, and 0-3 stars were interpreted as high risk of bias.

Study Selection
A flowchart of how studies have been selected is detailed in Figure 1. 507 potential manuscripts were obtained among all of the electronic search strategies. A total of 492 studies were excluded due to they did not meet the inclusion criteria. Additionally, a manual search was carried out to analyze the references cited in 15 of the articles that were included in this work. Finally, no more articles were incorporated from the manual search. In the end, a total of 15 studies were analyzed.

Study Characteristics
The 15 included studies were published between 2002 and 2022. Two studies do not reported the age of the participants [12,13]. The remaining studies reported mean ages between 40 and 90 years.
Only one study evaluated cerebral stroke/cerebrovascular accidents as an endpoint [8] and the conclusion achieved was that CCAAs often herald an ischaemic stroke. Four studies evaluated the influence of cardiovascular diseases in CCA [13][14][15]20].
The results are described in Table 2.

Study Characteristics
The 15 included studies were published between 2002 and 2022. Two studies do not reported the age of the participants [12,13]. The remaining studies reported mean ages between 40 and 90 years.
Only one study evaluated cerebral stroke/cerebrovascular accidents as an endpoint [8] and the conclusion achieved was that CCAAs often herald an ischaemic stroke. Four studies evaluated the influence of cardiovascular diseases in CCA [13][14][15]20].
The results are described in Table 2.  There was no significant association between periodontitis assessed as bone loss and CCAA - The sex-stratified analyses of cases disclosed an association between CCAA and periodontitis among men (OR, 1.83; 95% CI, 1.28 to 2.64; p < 0.01) but not among women (OR, 1.04; 95% CI, 0.52 to 2.08; p = 0.90).
-Participants with combined periodontitis and CCAA had a higher risk of having had myocardial infarction as compared with participants with either condition alone. -CCAA and periodontitis were associated with myocardial infarction in an independent manner rather than an interactive manner.   Table 3 details the risk of bias assessments. In view of the table, nine studies were found to have a moderate risk of bias and the other five studies had a low risk of bias. Biology 2022, 11, x 11 of 1 Table 3 details the risk of bias assessments. In view of the table, nine studies wer found to have a moderate risk of bias and the other five studies had a low risk of bias

Discussion
The aim of the present systematic review was to evaluate the reliability of panorami dental images in detecting carotid artery calcifications (CACs). Friendlander was the firs author to report, in 1981, the existence of soft tissue calcifications in panoramic image [7,27]. However, the questioning continues nowadays due to the conclusions of publishe studies in the field which evaluated whether carotid calcifications detected on panorami dental images are associated with future events of stroke and/or ischemic heart disease The conclusion was that the evidence of CCAs on panoramic images is related to an even of stroke and/or ischemic heart disease [28,29].
All studies included in the present review will be discussed in detail below. Table 3 details the risk of bias assessments. In view of the table, nine studies were found to have a moderate risk of bias and the other five studies had a low risk of bias

Quality Assessment
Rating scale: 7 to 9 stars = low risk of bias; 4 to 6 stars = moderate risk of bias; 0 to 3 stars = high risk of bias.

Discussion
The aim of the present systematic review was to evaluate the reliability of panoramic dental images in detecting carotid artery calcifications (CACs). Friendlander was the first author to report, in 1981, the existence of soft tissue calcifications in panoramic images [7,27]. However, the questioning continues nowadays due to the conclusions of published studies in the field which evaluated whether carotid calcifications detected on panoramic dental images are associated with future events of stroke and/or ischemic heart disease. The conclusion was that the evidence of CCAs on panoramic images is related to an event of stroke and/or ischemic heart disease [28,29].
All studies included in the present review will be discussed in detail below. Table 3 details the risk of bias assessments. In view of the table, nine studies were found to have a moderate risk of bias and the other five studies had a low risk of bias

Quality Assessment
Rating scale: 7 to 9 stars = low risk of bias; 4 to 6 stars = moderate risk of bias; 0 to 3 stars = high risk of bias.

Discussion
The aim of the present systematic review was to evaluate the reliability of panoramic dental images in detecting carotid artery calcifications (CACs). Friendlander was the first author to report, in 1981, the existence of soft tissue calcifications in panoramic images [7,27]. However, the questioning continues nowadays due to the conclusions of published studies in the field which evaluated whether carotid calcifications detected on panoramic dental images are associated with future events of stroke and/or ischemic heart disease. The conclusion was that the evidence of CCAs on panoramic images is related to an event of stroke and/or ischemic heart disease [28,29].
All studies included in the present review will be discussed in detail below. Table 3 details the risk of bias assessments. In view of the table, nine studies were found to have a moderate risk of bias and the other five studies had a low risk of bias

Quality Assessment
Rating scale: 7 to 9 stars = low risk of bias; 4 to 6 stars = moderate risk of bias; 0 to 3 stars = high risk of bias.

Discussion
The aim of the present systematic review was to evaluate the reliability of panoramic dental images in detecting carotid artery calcifications (CACs). Friendlander was the first author to report, in 1981, the existence of soft tissue calcifications in panoramic images [7,27]. However, the questioning continues nowadays due to the conclusions of published studies in the field which evaluated whether carotid calcifications detected on panoramic dental images are associated with future events of stroke and/or ischemic heart disease. The conclusion was that the evidence of CCAs on panoramic images is related to an event of stroke and/or ischemic heart disease [28,29].
All studies included in the present review will be discussed in detail below.  Table 3 details the risk of bias assessments. In view of the table, nine studies were found to have a moderate risk of bias and the other five studies had a low risk of bias

Quality Assessment
Rating scale: 7 to 9 stars = low risk of bias; 4 to 6 stars = moderate risk of bias; 0 to 3 stars = high risk of bias.

Discussion
The aim of the present systematic review was to evaluate the reliability of panoramic dental images in detecting carotid artery calcifications (CACs). Friendlander was the first author to report, in 1981, the existence of soft tissue calcifications in panoramic images [7,27]. However, the questioning continues nowadays due to the conclusions of published studies in the field which evaluated whether carotid calcifications detected on panoramic dental images are associated with future events of stroke and/or ischemic heart disease. The conclusion was that the evidence of CCAs on panoramic images is related to an event of stroke and/or ischemic heart disease [28,29].
All studies included in the present review will be discussed in detail below.   Rating scale: 7 to 9 stars = low risk of bias; 4 to 6 stars = moderate risk of bias; 0 to of bias.

Discussion
The aim of the present systematic review was to evaluate the reliabili dental images in detecting carotid artery calcifications (CACs). Friendland author to report, in 1981, the existence of soft tissue calcifications in pan [7,27]. However, the questioning continues nowadays due to the conclusio studies in the field which evaluated whether carotid calcifications detecte dental images are associated with future events of stroke and/or ischemi The conclusion was that the evidence of CCAs on panoramic images is rel of stroke and/or ischemic heart disease [28,29].
All studies included in the present review will be discussed in detail

Discussion
The aim of the present sys dental images in detecting car author to report, in 1981, the [7,27]. However, the questioni studies in the field which eval dental images are associated w The conclusion was that the ev of stroke and/or ischemic hear All studies included in th Bueno Marinho et al., 2020 [20] Biology 2022, 11, x 11 of 1 Table 3 details the risk of bias assessments. In view of the table, nine studies wer found to have a moderate risk of bias and the other five studies had a low risk of bias

Discussion
The aim of the present systematic review was to evaluate the reliability of panorami dental images in detecting carotid artery calcifications (CACs). Friendlander was the firs author to report, in 1981, the existence of soft tissue calcifications in panoramic image [7,27]. However, the questioning continues nowadays due to the conclusions of publishe studies in the field which evaluated whether carotid calcifications detected on panorami dental images are associated with future events of stroke and/or ischemic heart disease The conclusion was that the evidence of CCAs on panoramic images is related to an even of stroke and/or ischemic heart disease [28,29].
All studies included in the present review will be discussed in detail below.
Biology 2022, 11, x 11 of 15 Table 3 details the risk of bias assessments. In view of the table, nine studies were found to have a moderate risk of bias and the other five studies had a low risk of bias

Quality Assessment
Rating scale: 7 to 9 stars = low risk of bias; 4 to 6 stars = moderate risk of bias; 0 to 3 stars = high risk of bias.

Discussion
The aim of the present systematic review was to evaluate the reliability of panoramic dental images in detecting carotid artery calcifications (CACs). Friendlander was the first author to report, in 1981, the existence of soft tissue calcifications in panoramic images [7,27]. However, the questioning continues nowadays due to the conclusions of published studies in the field which evaluated whether carotid calcifications detected on panoramic dental images are associated with future events of stroke and/or ischemic heart disease. The conclusion was that the evidence of CCAs on panoramic images is related to an event of stroke and/or ischemic heart disease [28,29].
All studies included in the present review will be discussed in detail below.
Biology 2022, 11, x 11 of 15 Table 3 details the risk of bias assessments. In view of the table, nine studies were found to have a moderate risk of bias and the other five studies had a low risk of bias

Quality Assessment
Rating scale: 7 to 9 stars = low risk of bias; 4 to 6 stars = moderate risk of bias; 0 to 3 stars = high risk of bias.

Discussion
The aim of the present systematic review was to evaluate the reliability of panoramic dental images in detecting carotid artery calcifications (CACs). Friendlander was the first author to report, in 1981, the existence of soft tissue calcifications in panoramic images [7,27]. However, the questioning continues nowadays due to the conclusions of published studies in the field which evaluated whether carotid calcifications detected on panoramic dental images are associated with future events of stroke and/or ischemic heart disease. The conclusion was that the evidence of CCAs on panoramic images is related to an event of stroke and/or ischemic heart disease [28,29].
All studies included in the present review will be discussed in detail below.
Biology 2022, 11, x 11 of 15 Table 3 details the risk of bias assessments. In view of the table, nine studies were found to have a moderate risk of bias and the other five studies had a low risk of bias

Quality Assessment
Rating scale: 7 to 9 stars = low risk of bias; 4 to 6 stars = moderate risk of bias; 0 to 3 stars = high risk of bias.

Discussion
The aim of the present systematic review was to evaluate the reliability of panoramic dental images in detecting carotid artery calcifications (CACs). Friendlander was the first author to report, in 1981, the existence of soft tissue calcifications in panoramic images [7,27]. However, the questioning continues nowadays due to the conclusions of published studies in the field which evaluated whether carotid calcifications detected on panoramic dental images are associated with future events of stroke and/or ischemic heart disease. The conclusion was that the evidence of CCAs on panoramic images is related to an event of stroke and/or ischemic heart disease [28,29].
All studies included in the present review will be discussed in detail below.
Chang et al., 2018 [21] 2022, 11, x 11 of 15 Table 3 details the risk of bias assessments. In view of the table, nine studies were found to have a moderate risk of bias and the other five studies had a low risk of bias Rating scale: 7 to 9 stars = low risk of bias; 4 to 6 stars = moderate risk of bias; 0 to 3 stars = high risk of bias.

Discussion
The aim of the present systematic review was to evaluate the reliability of panoramic dental images in detecting carotid artery calcifications (CACs). Friendlander was the first author to report, in 1981, the existence of soft tissue calcifications in panoramic images [7,27]. However, the questioning continues nowadays due to the conclusions of published studies in the field which evaluated whether carotid calcifications detected on panoramic dental images are associated with future events of stroke and/or ischemic heart disease. The conclusion was that the evidence of CCAs on panoramic images is related to an event of stroke and/or ischemic heart disease [28,29].
All studies included in the present review will be discussed in detail below.  Table 3 details the risk of bias assessments. In view of the table, nin found to have a moderate risk of bias and the other five studies had a low Rating scale: 7 to 9 stars = low risk of bias; 4 to 6 stars = moderate risk of bias; 0 to of bias.

Discussion
The aim of the present systematic review was to evaluate the reliabili dental images in detecting carotid artery calcifications (CACs). Friendland author to report, in 1981, the existence of soft tissue calcifications in pan [7,27]. However, the questioning continues nowadays due to the conclusio studies in the field which evaluated whether carotid calcifications detecte dental images are associated with future events of stroke and/or ischemi The conclusion was that the evidence of CCAs on panoramic images is rel of stroke and/or ischemic heart disease [28,29].
All studies included in the present review will be discussed in detail

Discussion
The aim of the present sys dental images in detecting car author to report, in 1981, the [7,27]. However, the questioni studies in the field which eval dental images are associated w The conclusion was that the ev of stroke and/or ischemic hear All studies included in th (4) Friedlander et al., 2002 [22] 2022, 11, x 11 of 15 Table 3 details the risk of bias assessments. In view of the table, nine studies were found to have a moderate risk of bias and the other five studies had a low risk of bias Rating scale: 7 to 9 stars = low risk of bias; 4 to 6 stars = moderate risk of bias; 0 to 3 stars = high risk of bias.

Discussion
The aim of the present systematic review was to evaluate the reliability of panoramic dental images in detecting carotid artery calcifications (CACs). Friendlander was the first author to report, in 1981, the existence of soft tissue calcifications in panoramic images [7,27]. However, the questioning continues nowadays due to the conclusions of published studies in the field which evaluated whether carotid calcifications detected on panoramic dental images are associated with future events of stroke and/or ischemic heart disease. The conclusion was that the evidence of CCAs on panoramic images is related to an event 0 Biology 2022, 11, x Table 3 details the risk of bias assessments. In view of the table, nin found to have a moderate risk of bias and the other five studies had a low Rating scale: 7 to 9 stars = low risk of bias; 4 to 6 stars = moderate risk of bias; 0 to of bias.

Discussion
The aim of the present systematic review was to evaluate the reliabili dental images in detecting carotid artery calcifications (CACs). Friendland author to report, in 1981, the existence of soft tissue calcifications in pan [7,27]. However, the questioning continues nowadays due to the conclusio studies in the field which evaluated whether carotid calcifications detecte dental images are associated with future events of stroke and/or ischemi The conclusion was that the evidence of CCAs on panoramic images is rel  Table 3 details the risk o found to have a moderate risk Rating scale: 7 to 9 stars = low risk of bias.

Discussion
The aim of the present sys dental images in detecting car author to report, in 1981, the [7,27]. However, the questioni studies in the field which eval dental images are associated w The conclusion was that the ev  Table 3 details the risk of bias assessments. In view of the table, nine studies were found to have a moderate risk of bias and the other five studies had a low risk of bias

Quality Assessment
Rating scale: 7 to 9 stars = low risk of bias; 4 to 6 stars = moderate risk of bias; 0 to 3 stars = high risk of bias.

Discussion
The aim of the present systematic review was to evaluate the reliability of panoramic dental images in detecting carotid artery calcifications (CACs). Friendlander was the first author to report, in 1981, the existence of soft tissue calcifications in panoramic images [7,27]. However, the questioning continues nowadays due to the conclusions of published  Table 3 details the risk of bias assessments. In view of the table, nin found to have a moderate risk of bias and the other five studies had a low Rating scale: 7 to 9 stars = low risk of bias; 4 to 6 stars = moderate risk of bias; 0 to of bias.

Discussion
The aim of the present systematic review was to evaluate the reliabili dental images in detecting carotid artery calcifications (CACs). Friendland author to report, in 1981, the existence of soft tissue calcifications in pan [7,27]. However, the questioning continues nowadays due to the conclusio Biology 2022, 11, x

Discussion
The aim of the present sys dental images in detecting car author to report, in 1981, the [7,27]. However, the questioni (4) Friedlander et al., 2013 [24] 2022, 11, x 11 of 15 Table 3 details the risk of bias assessments. In view of the table, nine studies were found to have a moderate risk of bias and the other five studies had a low risk of bias

Quality Assessment
Rating scale: 7 to 9 stars = low risk of bias; 4 to 6 stars = moderate risk of bias; 0 to 3 stars = high risk of bias.

Discussion
The aim of the present systematic review was to evaluate the reliability of panoramic dental images in detecting carotid artery calcifications (CACs). Friendlander was the first 0 Biology 2022, 11, x Table 3 details the risk of bias assessments. In view of the table, nin found to have a moderate risk of bias and the other five studies had a low Rating scale: 7 to 9 stars = low risk of bias; 4 to 6 stars = moderate risk of bias; 0 to of bias.

Discussion
The aim of the present systematic review was to evaluate the reliabili dental images in detecting carotid artery calcifications (CACs). Friendland

Discussion
The aim of the present sys dental images in detecting car (4) Friedlander et al., 2015 [20] 2022, 11, x 11 of 15 Table 3 details the risk of bias assessments. In view of the table, nine studies were found to have a moderate risk of bias and the other five studies had a low risk of bias

Quality Assessment
Rating scale: 7 to 9 stars = low risk of bias; 4 to 6 stars = moderate risk of bias; 0 to 3 stars = high risk of bias.

Discussion
Friedlander et al., 2016 [25] Biology 2022, 11, x 11 of 1     Table 3 details the risk of bias assessments. In view of the table, nine studies were found to have a moderate risk of bias and the other five studies had a low risk of bias  Table 3 details the risk of bias assessments. In view of the table, nine studies were found to have a moderate risk of bias and the other five studies had a low risk of bias with 1650 patients older than 45 years. The participants were divided into two groups. Authors present a number of limitations. The most important is the need to clarify the clinical significance between panoramic images and Doppler ultrasonography, in addition to the analysis of the intensity, size, and shape of the calcification in the area of the carotid arteries on the panoramic images. The low number of participants in the study is also a limitation. Authors concluded that doctors must be aware of CCA on routine panoramic dental images, particularly in older patients. Bayram et al. [14] evaluate the digital panoramic radiographs of 4106 patients older than 40 years for CAAs. Authors analyzed diabetes, diastolic blood, total cholesterol, smoking, and atherosclerosis, among other medical factors of participants, and concluded that the incidence of CCA was higher on the left side and that there were no statistically significant relationships between cardiovascular disease, coronary risk factors, and CAAs. Authors do not mention any limitation of their study.

Quality Assessment
Bueno Marinho et al. [20] investigate the prevalence of CCA on panoramic radiographs of 67 patients with liver cirrhosis and a mean age of 55 years. Authors concluded that cirrhotic patients are more likely to have CCA compared to healthy patients, and this risk increases significantly when kidney disease is involved. Authors do not mention any limitation of their study.
Chang et al. [21] analyzed if severity of obstructive sleep apnea is associated with the presence of CCA seen on 108 panoramic images. The study concluded that there is a strong association between severity of obstructive sleep apnea and the presence of CCA that can be seen on panoramic images. Authors mentioned two limitations: the small sample size and the use of a single center from where the data were collected.
Friedlander et al. [18] aimed to analyzed if the prevalence of atheromas is less in patients whose diabetes is noninsulin-treated compared with patients whose diabetes is insulin-treated. 46 neurologically asymptomatic patients (mean age 68.5 years) with type 2 diabetes were included in this study. Authors demonstrate that people with type 2 diabetes, irrespective of treatment modality, have high rates of atheromas. Authors do not mention any limitation of their study.
Friedlander et al. [22] evaluated the relationship between CCA on panoramic images and breast arterial calcifications on mammograms and concluded that there was not a relationship. A total of 40 women (mean age 62.2 years old) participated in the study.
Friedlander et al. [23] evaluated the presence of CCA on panoramic dental images on patient with primary hyperparathyroidism as a risk of factor of cardiovascular events on military veterans older than 50 years old. Authors concluded that CCA are often seen on the panoramic images of patients with primary hyperparathyroidism.
Friedlander et al. [24] studied the prevalence and severity of aortic arch calcifications on posterior-anterior chest radiographs women who also had CCAs visible on their panoramic images. This study concluded that prevalence of carotid plaque on panoramic images of women is significantly associated with presence of aortic arch calcifications on chest radiographs.
Friedlander et al. [25] assessed the possibility of CCA shedding emboli by observing their relationship with ipsilateral retinal emboli in males with diabetes, and the conclusion was that some male patients with diabetes mellitus type II having calcified carotid artery atheromas in the bifurcation area may have significant sequelae as evidenced by retinal artery emboli.
Friedlander et al. [12] determined the prevalence of calcified carotid artery atheromas in old men with gout. This study determined that CCAs often herald an ischaemic stroke in patients with gout, especially those with increased age, dyslipidaemia or diabetes.
Friedlander et al. [26] concluded that there is a strong association between the presence of CCAP seen on panoramic images of older males and extent of systemic inflammation as evidenced by elevated neutrophillymphocyte ratios.
Gustaffsson et al. [16] aimed to analyze the association between periodontitis and CCAAs among patients with a recent myocardial infarction and controls without a myocar-dial infarction and to evaluate whether CCAA combined with periodontitis is associated with myocardial infarction. The conclusion was that patients with periodontitis displayed CCAA in panoramic radiographs significantly more frequently than those without that dental disease, independent of whether the person had had a recent myocardial infarction. Participants with periodontitis combined with CCAA had a higher risk of having had a myocardial infarction than participants with either condition alone.
Ohba et al. [15] evaluated the incidence among 80-year-olds of CCAAs as detected on panoramic radiographs and concluded that panoramic images can be employed to detect CCA.
Patil et al. [19] evaluated the prevalence of calcified carotid artery atheromas detected on panoramic radiographs of patients with renal stones and assessed the correlation of renal stones and carotid artery calcifications. Their results concluded that there is no significant relationship between the presence of calcified carotid artery in the patients with renal stones and the control group.

Conclusions
The evidence in the literature was found to be equivocal. There are contradictory results regarding if there is or not a significant relationship between cardiovascular disease and CCA seen in panoramic images. However, the findings of this systematic review exhibits that panoramic radiographs can be used for dental diagnosis and treatment planning, as well as to detect calcified carotid artery atheromas. Therefore, panoramic images can be employed to alert clinicians and can provide potentially life-saving information.
Other risks of factors, such as age, diabetes, total cholesterol, obesity, diet, race, gender, or family history of cardiovascular diseases, must be evaluated to predict adverse vascular events. In view of the results achieved in the present review, diabetes mellitus, hypertension, and age should be the most important incident of strokes.
X-ray images must be analyzed carefully by practitioners in patients with risk, such as age, diabetes, or hypertension, in order to offer special indications.