Principais achados incidentais em tomografia computadorizada de feixe cônico na região de cabeça e pescoço e o impacto na vida dos pacientes: uma revisão integrativa de literatura

SOUZA, Diego Leonardo de; RAMOS, Mario Eduardo Escobar; CORRÊA, Márcio

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REVIEW • Rev Gaúch. Odontol. 70 • 2022 • https://doi.org/10.1590/1981-86372022004720200091 copiar

Principais achados incidentais em tomografia computadorizada de feixe cônico na região de cabeça e pescoço e o impacto na vida dos pacientes: uma revisão integrativa de literatura

Autoria SCIMAGO INSTITUTIONS RANKINGS

RESUMO

Identificar os principais achados incidentais na região de cabeça e pescoço com o uso de Tomografia Computadorizada de Feixe Cônico (TCFC) e os impactos na vida dos pacientes. O estudo foi realizado utilizando como método a revisão integrativa, iniciado com pergunta norteadora seguida de buscas nas bases de dados Pubmed, Scopus, Biblioteca Virtual em Saúde e Dentistry & Oral Sciences Source por trabalhos de 2009 até o ano de 2019. Tornaram-se objeto deste trabalho quarenta e um artigos. Os achados incidentais mais relatados pelos artigos estão presentes nas regiões ósseas e de ATM, sendo encontrados 35 diferente AIs. No entanto, eles também são comuns em vias aéreas, como o espessamento de mucosa e cistos de retenção mucoso. Entre os dentários, os mais apontados são dentes impactados e supranumerários. Já no grupo das calcificações de tecidos moles, o tonsilólito e as calcificação do processo estilo-hióide são as mais frequentes. Ateromas e lesões malignas são achados com menor prevalência, mas importantes devido ao impacto na vida do paciente. Os principais achados incidentais são os ósseos/ATM, seguidos pelos dentários, as calcificações de tecidos moles, os das vias aéreas e outros achados. A maioria deles não afetam a vida do paciente. Porém, alguns AIs requerem intervenções imediatas e geralmente estão associadas a pacientes idosos. Por fim, mais da metade dos estudos apontaram que os achados incidentais estão localizados em região extragnática.

Termos de indexação
Achados incidentais; Tomografia Computadorizada de feixe cônico; Diagnóstico por imagem

Number	Year and country	Author	Kind of study	Sample	Main conclusions
1	2011, Switzerland	Pazera et al.	Retrospective description	139 CBCT	In 46.8% of the sample, AIs were identified, most of them in the airways
2	2011, Wales	Rogers et al.	Case report	4 CBCT	Highlights the need for the entire volume of CBCTs to be retaliated by trained professionals.
3	2012, Turkey	Çağlayan & Tozoğlu	Clinical Trial	207 patients	In 92% of the sample, AIs were found, most of them in the airways; Radiologists should assess the images comprehensively .
4	2011, USA	Price et al.	Retrospective description	300 CBCT	AIs are frequent in CBCT exams; Careful and complete interpretation of images is required beyond the region of interest to avoid neglect of hidden pathologies.
5	2012, Japan and USA	Enciso et al.	Retrospective description	53 patients	Patients with obstructive sleep apnea (OSA) have a higher% of AIs in the region of the airways compared to patients without OSA.
6	2013, USA	Almong et al.	Case report	1 patient	Calcifications in the carotid artery can be visualized on CBCT; Need for referral to an appropriate professional for further investigation.
7	2013, USA	Edwards et al.	Systematic review	5 Articles	AIs are frequent in CBCT images and vary in terms of frequency and nature; Most are extragnatic findings; The effect of these AIs in terms of the requirement for follow-up care, intervention and the potential expense of subsequent treatment requires further investigation.
8	2013, USA	Barghan et al.	Case report	2 patients	Skeletal and soft tissue pathologies can be detected in CBCT; CBCT exams should be analyzed in full volume by an experienced professional, especially when using a large FOV.
9	2014, USA	Mahdian et al.	Retrospective description	30 CBCT	CBCT was more effective in diagnosing the extension, pattern, and location of the hyoid-style ligaments compared to panoramic radiographs.
10	2014, Canada	Edwards et al.	Retrospective description	427 CBCT reports and medical records	High occurrence of AIs in CBCT with large FOVs in an orthodontic population. (83.4%); Most of the AIs in an extragnatic region; Need for a comprehensive review of the entire volume of data, regardless of the area of interest.
11	2014, England	Doğramacı et al.	Retrospective description	183 CBCT	In 83% of the sample, AIs were found; Most of these findings in exams with small FOV focused on impacted canine teeth required little immediate intervention (0.3%). 28% of the sample needed follow-up.
12	2013, Netherlands	Kuijpers et al.	Retrospective description	284 CBCT	High frequency of AIs (95.1%); The prevalence of incidental findings is three times higher in patients with cleft lip and palate (CLP) compared to healthy patients; Many of the findings are related to problems arising from the CLP, so the examination of CBCT in patients with cleft requires careful and thorough interpretation by specialists.
13	2012, Not informed	Steier et al.	Case report	1 patient	It is important that CBCT scans are interpreted by properly trained and experienced radiologists or dentists in order to provide maximum benefit to the patient.
14	2014, USA	Miles, Danforth	Systematic review	Uninformed	Importance of making reports that point out the AIs, because based on them, patients can make decisions about their health, since they will have all the information about the findings.
15	2015, USA	Husain et al.	Case report	4 patients	Intervertebral pneumocysts can be detected as AIs in CBCT; Familiarity with the demographic and radiographic characteristics of this lesion is important for dentists and oral and maxillofacial radiologists to avoid unnecessary investigations of this benign and innocuous lesion and to avoid causing alarm to patients.
16	2015, USA	Newaz et al.	Case report	2 patients	Adequate diagnostic management required when incidental findings are discovered.
17	2015, Taiwan	Chen et al.	Retrospective description	500 CBCT	The prevalence of posticus dots (PP) can be assessed by CBCT. The imaging findings show the largest articular facet of the upper atlas (FAAS) on the PP side and the largest left-right difference in the FAAS area in patients with unilateral PP.
18	2015, Canada	Edwards et al.	Retrospective description	18 CBCT	He concluded that among the evaluators considered experienced in CBCT, the agreement on the diagnosis of AIs was “fair to good”, whereas the intra-evaluator agreement was “excellent”.
19	2016, Switzerland	Togan et al.	Retrospective description	999 CBCT	Fully analyze the entire volume of the exam; Dentists should be aware of the frequency and location of these findings and investigate further the clinically important ones beyond the region of main interest; Relevant incidental findings should be mentioned to students and included in dentist education in order to improve awareness for clear assessment and identification in all CBCT images.
20	2018, USA	Frazier et al.	Case report	1 patient	Mönckeberg’s medial calcinosis is a form of arteriosclerosis is a benign condition that most commonly affects the facial arteries and is usually an incidental radiographic finding. The importance of its recognition is to alert the clinician about possible serious underlying systemic diseases, especially diabetes and chronic kidney disease.
21	2017, Brazil	Lopes et al.	Retrospective description	150 CBCT	AIs were found in 92% of the studied samples; Most incidental findings do not require treatment or referral; The entire volume of the imaging exam must be assessed.
22	2017, USA	Oser et al.	Retrospective description	203 CBCT	The study demonstrated that a radiologist is significantly more likely to report incidental findings of CBCT with small FOV than in a resident in endodontics; Based on the high percentage of findings that were not noticed, we recommend that dentists and doctors consider that small FOV CBCT be analyzed and reported by a trained radiologist. If this is not an option, it is important to have adequate training to read these specific checks; It is important to thoroughly review the entire volume on all vision plans, write down all findings in the patient’s record, review the findings with the patient and refer him if incidental findings require additional treatment.
23	2017, Canada	Alsufyani et al.	Retrospective description	7.689 CBCT reports	AIs in the cervical spine or in the Clivus are not common (9.5%), but they can be significant; several findings may be associated with an increased risk of subsequent neurological impairment due to spinal cord instability and invasion. As such, they must be recognized and interpreted, with the recognition of the potential need for additional radiographic investigation beyond what the CBCT can offer.
24	2017, USA	Albert & Mupparapu	Case report	1 patient	They proposed a classification for mesiodens; This classification would be a useful tool to guide the dentist or specialist towards proper treatment options and planning.
25	2019, Italy	Borghesi et al.	Retrospective description	1.328 CBCT	The study reported the incidence, morphology and gender relationship of three-root upper premolars (PMSTR); Improving our knowledge of the presence and characteristics of this anatomical variant can help to increase the success rates of root canal treatments.
26	2019, Turkey	Bayrak et al.	Retrospective description	573 CBCT	The CBCT imaging system is used as a common tool for dental diagnosis and treatment planning before and after surgical procedures and can be used to evaluate intracranial calcifications, as it allows the image of bone and calcified structures. An important point is that CBCT has significant limitations in the image of anatomical structures. Common CT scans are more accurate in the diagnosis of intracranial calcifications, being more sensitive, specific and superior in this regard.
27	2014, Iran	Shokri, A., et al.	Retrospective description	100 CBCT	Septication of paranasal sinuses were the most frequently found AIs;
28	2015, India	Warhekar et al.	Retrospective description	795 CBCT	The most common findings incidentally diagnosed in CBCT were orofacial malignancies (1.4%) followed by pathologies of the maxillary sinuses. Although the oral radiologist makes the specialist aware of the incidental finding and assesses the possibility of an underlying disease, they must be confirmed based on histopathological findings.
29	2016, Not informed	Damaskos et al.	Retrospective description	484 CBCT	The identification of certain anatomical landmarks allows the detection of AIs along the segments of the internal carotid artery, including the extracranial C1 and petrous intracranial (C2), lacerum (C3), cavernous (C4), clinoid (C5) and ophthalmological (C5) segments C6); In the studied cohort, the frequency of calcification increases in segments C1, C5 / C6 and C4; The severity of calcification increases with increasing age, especially in segments C1, C4 and C5 / C6, regardless of gender; These findings would help to identify the extent of atherosclerotic burden in dental patients, who should be referred for evaluation, both for the presence of intracranial stenosis and white matter lesions.
30	2016, Brazil and Greece	Silveira et al.	Retrospective description	406 CBCT	Equal distribution of incidental representation of extra and intracranial soft tissue calcifications over the course of the ICA between 2 different populations aged ≥ 40 years from 2 different continents; Increasing age was clearly a predisposing factor in the presence of these calcifications; This should alert dentists to the need for additional evaluation by their patients by specialized doctors about the importance of these findings, because their presence is defined as a vascular risk factor for stroke.
31	2017, Spain	Ata-ali et al.	Systematic review	23 articles	There is no consensus on the cut-off point beyond which the thickening of the maxillary sinus mucosa should be considered pathological, and the definition of maxillary sinusitis also varies widely in the scientific literature. In this sense, an international consensus is needed in relation to these concepts, with a clear distinction between healthy and sick maxillary sinuses, in order to facilitate comparisons between studies.
32	2017, Saudi Arabia	Zain-alabdeen & Khateeb	Retrospective description	150 CBCT	Confirms the high prevalence of accidental maxillofacial findings in CBCT exams (92.2%); This result emphasizes the need to thoroughly examine CBCT volumes for clinically significant results, not only within the region of interest, but beyond. This approach benefits the patient and protects the professional.
33	2019, USA	Dief et al.	Systematic review	10 articles	It contributes to the importance of complete CBCT readings and the value of proper diagnosis of AIs; Although CBCT has been shown to be useful in dentistry, particularly in reference to the indication of dental implants and other indications, CBCT should be used as a secondary radiographic tool, with conventional radiographs remaining as the first option; although CBCT scans can improve treatment planning, there are more responsibilities associated with AIs in CBCT scans compared to conventional radiographs, especially since CBCT scans can cover areas that dentists may not be familiar with.
34	2017, Saudi Arabia	Al-Zoubi et al.	Retrospective description	412 CBCT	The prevalence of incidental pathologies of the maxillary sinuses is higher in asymptomatic patients seen at dental clinics. Therefore, dentists should be aware of these incidental abnormalities seen in the maxillary sinus. A thorough analysis of the entire CBCT scan helps professionals to accurately diagnose and make timely referrals, comprehensive treatment planning and follow-up.
35	2018, Brazil	Missias et al.	Retrospective description	1.000 CBCT	A high prevalence of soft tissue calcification was detected in CBCT exams with different sizes of FOV (62.6%). Although most cases do not require treatment or referral to another professional, they emphasized the importance of a thorough evaluation of imaging tests and the great contribution of CBCT to the diagnosis of soft tissue calcifications.
36	2018, Hong Kong	Kawai et al.	Retrospective description	169 CBCT	Radiodensities in the maxillary sinus were observed in 16.6% of asymptomatic patients; Periodontal pathology in the posterior maxilla seems to be an influencing factor in the presence of sinus radiodensities; Age and morphological changes in the sinus mucosa seem to be influencing factors in the shape of the radiodensities.
37	2017, Brazil	Flaiban et al.	Retrospective description	202 CBCT	The prevalence of incidental findings in CBCT performed for orthodontic purposes is high (227 AIs in 202 CBCT); The entire volume of the exam must be analyzed.
38	2019, Brazil	Oliveira et al.	Retrospective description	175 CBCT	Although no significant difference was observed in relation to the age and side of the face observed, or the prevalence and total number of each of the incidental findings, he observed that some changes are more likely to be observed bilaterally.
39	2012, USA	Allareddy et al.	Retrospective description	1.000 CBCT	In 94.3% of the examinations, AIs were found. From the wide and comprehensive scope of discoveries found inside and outside the main areas of interest of the 1000 subjects, it can be concluded that it is essential that a person trained in advanced techniques of interpretation in radiology interprets the CBCT images. It can also be concluded that these CBCT images need to be reviewed comprehensively.
40	2012, USA	Pette et al.	Retrospective description	318 CBCT	The findings of this study suggest that there are many significant pathological findings unrelated to dentistry that can be detected by cone beam computed tomography (CBCT) with a wide field of view. Additional investigations should be carried out to determine the sensitivity and specificity of these radiological findings in relation to their true medical pathological diagnoses and relevance; It is not known whether CBCT scans will be a valuable screening tool for common systemic conditions such as cardiovascular disease, sinusitis and osteoarthritis or whether many false positive results will be detected, resulting in unnecessary medical examinations.
41	2016, USA	Syed & Mupparapu	Case report	4 Patients	CBCT is a relatively new technology in dentistry; As the CBCT findings include areas at the base of the skull that are not primarily intended for analysis, oral and maxillofacial radiologists have an obligation to identify, review and report anatomical variations of the skull base and prevent the initiation of other unnecessary images by dentists . The navicular fossa is one of those anatomical variations that affect the basiocipipital and is similar to canalis basilaris medianus, which also affects the basiocipipital.

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[1] Correspondênce to: DL Souza. E-mail: diego.220v@hotmail.com.

Airways	Dentals	Bone/TMJ
Mucosal thickening (18) Mucous polyps (16) Deviated septum (14) Hypertrophic shells (4) Bubble shells (12) Mucous retention cysts (16) Sinusitis Signs (12) Signs of Pansinusitis (5) Oroantral fistula (3) Anthrolites (7) Hypertrophic Tonsils (6) Maxillary sinus hypoplasia (4) Maxillary sinus aplasia (2) Nasopalatine duct cyst (5)	Enamel Pearls (4) Supernumerary tooth (13) Supernumerary root (1) Impacted teeth (9) Periapical lesion (6) Sclerosis and periapical rarefaction (1) Root fracture (2) Dentigerous cyst (5) Residual cyst (2) Odontoma (6) Macrodontics (1) Fusion (2) Hypodontia (2) Microdontia (2) Twinning (2) Root tearing (4) Root shortening (2) Ectopic position (1) Other odontogenic cysts (2) Caries (2) Vestibular bifurcation cyst (1) Internal resorption (2) External resorption (6) Claw cusp (1) Bullfighting (2) Dens in tooth (3) Bone loss (1) increased periodontal ligament (3) Odontogenic keratocyst tumor (4) Lateral periodontal cyst (1) Cementoblastoma (2) Residual root (3) Ameloblastoma (2)	Vertebrae crack (1) Bifid mandible condyle (9) Mandibular condyle erosion (4) Osteophytes (12) Condensing osteitis (6) Periapical rarefied osteitis (7) Cemento-osseous dysplasia (5) Simple bone cyst (3) Idiopathic sclerosis (5) Palatine torus (3) Mandibular torus (4) Exostoses (3) Osteoma (5) Stafne bone defect (3) Condyle flattening (6) Subchondral sclerosis of the TMJ (3) TMJ erosion (3) Degeneration of vertebrae (3) Fibrous dysplasia (8) Fusion of vertebrae (5) Flattening of vertebrae (1) Osteoarthritis / cervical osteoarthritis (5) Rotation of vertebrae (1) Presence of ossicles in the vertebra (2) Vertebral Pontiac (3) Increased Turkish saddle (3) Condylar hypoplasia (6) Physiological remodeling of the TMJ (3) Vertebral pneumocysts (2) Empty Turkish saddle (1) Giant cell injury (3) Condylar hyperplasia (2) Navicular fossa (1) TMJ subondral pseudocyst (4) TMJ degeneration (5)
Soft tissue calcifications
Sialolite (10) Calcification of the common carotid artery (11) Intracranial calcification of the internal carotid artery (5) Calcification of hyoid-style ligament (12) Tonsilloliths (14) Calcification of thyroid cartilage (4) tritical cartilage (2) Calcification of Falx Celebri (1) Calcification of the pineal gland (6) Lymph node calcification (6) Cutaneous osteoma (4) Calcification of paranasal sinus (2) Dental pulp calcification (2) Medial calcinosis of Mönckeberg (1) Calcification of interclinoid ligament (1)
Other findings
Foreign bodies (4) Intra-hemispheric lipoma (1) Notocordal cell tumor (1) Atheroma (3) Malignant Injuries * (3)