ABSTRACT
To identify the main incidental findings (IFs) in the head and neck region using Cone-Beam Computed Tomography (CBCT) and the impact on patient’s live. The study was carried out using an integrative review method, starting with a guiding question followed by searches in the databases Pubmed, Scopus, Virtual Health Library and Dentistry & Oral Sciences Source for articles from 2009 until 2019. Forty-one articles became the object of this work. The incidental findings most reported by the articles are present in the bone and TMJ regions, with 35 different AIs being found. However, they are also common in the airways, such as mucosal thickening and retention mucosal cysts. Among the dental, the most pointed are impacted and supernumerary teeth. In the group of soft tissue calcifications, tonsillolite and calcification of the hyoid-style process are the most frequent. Atheroma and malignant lesions are less prevalent, but important due to the impact on patient’s life. The main incident findings are bone / TMJ, followed by dental, soft tissue calcifications, airways and other findings. Most of them do not affect patient’s life. However, some IFs require immediate interventions and are generally associated with elderly patients. Finally, more than half of the studies pointed out that the incidental findings are located in an extragnatic region.
Indexing terms
Incidental findings; Cone Beam Computed Tomography; Diagnostic imaging
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
INTRODUCTION
With the advancement of technology, much has been developed in the radiology area, In this sense, we can say that the advent of CBCT has made the diagnosis faster and more accurate, giving the development of equipment and easy access to the exam [11 Soares FAP, Pereira AG, Flôr RC. Utilização de vestimentas de proteção radiológica para redução de dose absorvida: uma revisão integrativa da literatura. Radiol Bras. 2011; 44(2):97-103. https://dx.doi.org/10.1590/S0100-39842011000200009
https://doi.org/10.1590/S0100-3984201100...
]. In addition, it has been benefited for dentistry, because it provides excellent images analyzes information, mainly maxillofacial bone anatomy and teeth at a potentially lower radiation dose, lower cost for the patient compared to multi-detector computed tomography [22 Price JB, Thaw KL, Tyndall DA, Ludlow JB, Padilla RJ. Incidental findings from cone beam computed tomography of the maxillofacial region: a descriptive retrospective study. Clin Oral Implants Res. 2012;23(11):1261-1268. https://dx.doi.org/10.1111/j.1600-0501.2011.02299.x.
https://doi.org/10.1111/j.1600-0501.2011...
], and allows the professional to evaluate patients for a variety of illnesses [33 Cağlayan F, Tozoğlu U. Incidental findings in the maxillofacial region detected by cone beam CT. Diagn Interv Radiol. 2012;18(2):159-163. https://dx.doi.org/10.4261/1305-3825.DIR.4341-11.2
https://doi.org/10.4261/1305-3825.DIR.43...
].
With the evolution of CBCT devices, it became possible to obtain images of fields of view (FOV) of varying sizes. In light of this and combined with the quality of these exams, the responsibility of the dental surgeon (DC) and the radiologist has grown since there is a greater chance to find incidental findings (IFs), which are those whose discovery occurs by chance, that means, finds based on an examination carried out for another purpose [33 Cağlayan F, Tozoğlu U. Incidental findings in the maxillofacial region detected by cone beam CT. Diagn Interv Radiol. 2012;18(2):159-163. https://dx.doi.org/10.4261/1305-3825.DIR.4341-11.2
https://doi.org/10.4261/1305-3825.DIR.43...
]. Several authors point out that these discoveries can affect patients’ lives in several ways with a consensus that tells: a careful and complete interpretation of the CBCT images is necessary beyond the region of interest to avoid neglecting diseases that are eventually not showing symptoms and that are discovered early as an IF [22 Price JB, Thaw KL, Tyndall DA, Ludlow JB, Padilla RJ. Incidental findings from cone beam computed tomography of the maxillofacial region: a descriptive retrospective study. Clin Oral Implants Res. 2012;23(11):1261-1268. https://dx.doi.org/10.1111/j.1600-0501.2011.02299.x.
https://doi.org/10.1111/j.1600-0501.2011...
].
After performing the imaging exam, it is up to the radiologist and the requester to complete the analysis of the entire volume of data, since a complete analysis allows the detection of IFs with significant or not clinical potential [22 Price JB, Thaw KL, Tyndall DA, Ludlow JB, Padilla RJ. Incidental findings from cone beam computed tomography of the maxillofacial region: a descriptive retrospective study. Clin Oral Implants Res. 2012;23(11):1261-1268. https://dx.doi.org/10.1111/j.1600-0501.2011.02299.x.
https://doi.org/10.1111/j.1600-0501.2011...
]. Ignoring part of the exam can be dangerous, since most IFs are extragnatic [44 Edwards R, Altalibi M, Flores-Mir C. The frequency and nature of incidental findings in cone-beam computed tomographic scans of the head and neck region: a systematic review. J Am Dent Assoc. 2013;144(2):161-170. https://dx.doi.org/10.14219/jada.archive.2013.0095
https://doi.org/10.14219/jada.archive.20...
] and, therefore, outside the region of common interest of DCs. However, this does not exempt them from legal responsibility. Therefore, a better understanding of the IFs revealed by the CBCT images can help professionals to identify significant injuries. This article is an integrative review and aims to identify the main IFs in the head and neck region with the use of CBCT and the impact on patients’ lives.
This research is an integrative literature review. The integrative review has six steps: 1) identification of the theme; 2) establishment criteria for inclusion and exclusion of studies/sampling or literature search; 3) definition of the information to be extracted from the selected studies/study customization; 4) evaluation of the studies included in the integrative review; 5) interpretation of results and 6) presentation of the review/synthesis of knowledge.
The research started with a guiding question, “What are the main IFs in CBCT in head and neck region and the impact on the patient’s life?”. Health Sciences and MeSH (Medical Subject Headings). The terms selected were: “Incidental findings”, “Cone-beam computed tomography” and “Diagnostic imaging”. Making the search keys, all terms and their synonyms in Portuguese, English, and Spanish were used. With the search strategy defined, Pubmed, Scopus, Dentistry and Oral Sciences Source, Virtual Health Library (VHL / Lilacs, BBO), and Scielo were consulted. The inclusion criteria defined for this research were: articles published between 2009 and 2019, written in Portuguese, English, or Spanish, regardless of the number of samples, which presented in the title, abstract, or body of the article at least two of the aforementioned terms. The exclusion criteria used were: articles that were not available in full free of charge, letters to the editor, editorials, and works not related to the area of dentistry. The research resulted in 265 papers, after reading titles, abstracts and applying the inclusion and exclusion criteria, 167 articles were discarded. After analysis and removal of duplicates, 41 studies became the object of this research. Figure 1 illustrates the selection process.
Synthesis of the selection of articles after searching, application of inclusion criteria, reading of titles and abstracts and elimination of repeated works, and reading of articles in full.
In possession of these articles, the studies were categorized. In this stage, the objective was to organize and summarize the information in a succinct aspect, forming a database of easy access and management [55 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto contexto - Enferm. 2008;17(4):758-764. https://dx.doi.org/10.1590/S0104-07072008000400018
https://doi.org/10.1590/S0104-0707200800...
]. In this way, extraction of information from the works was applied: year of publication, country of publication, name of the authors, type of study, quantity/number of the sample, and the main conclusions. From these data, the main themes reported by the authors were grouped, thus obtaining two major groups, namely: 1) CBCT and the main incidental findings and 2) The impact of IFs on patients’ lives.
RESULTS
We highlight 101 incidental findings as the main ones, as they are the most reported in the articles that make up this review. We divided these AIs into 5 large groups, namely: 1 - airway findings, 2 - dental findings, 3 - soft tissue calcifications, 4 - bone and TMJ findings, and 5 - other findings.
The literature points to the airway group as a commonplace to find IFs. In this sense, 14 IFs were detected in the articles, emphasizing the thickening of the mucosa, reported in 18 studies, followed by the mucous retention cyst described in 16, the mucous polyp also pointed out in 16 articles and the deviated septum expressed in 14.
In the group of dental findings, 33 different IFs were registered in the 41 studies evaluated, with emphasis on the supernumerary teeth, mentioned in 13 studies, the impacted teeth described in 9 articles, and the enamel pearls in 4.
In the third group, which concerns soft tissue calcifications, tonsillitis reported in 14 articles stand out, calcification of the style-hyoid process in 12, calcifications of the common carotid artery that were expressed in 11 articles, the pineal gland is calcified in 6 and the intracranial calcification of the carotid artery, which was mentioned in 5 studies.
The group of bone / TMJ findings was the one that most presented IFs, with 35 findings. The osteophytes described in 12 articles stand out, the condyle of the bifid mandible in 9 articles, fibrous dysplasia in 8, and degenerative changes in 3 studies.
Finally, in the fifth group, called “other findings”, foreign bodies were more frequently identified in 4 studies, atheroma in 3 and malignant lesions also in 3. Chart 1 describes all the incidental findings, as well as the number of articles that have been reported.
Main incidental findings reported in the 41 articles that make up this integrative review and number of articles that report them (n).
Investigating the literature, we also noticed that the number of incidental extragnatic findings is high, totaling 68 IFs outside the region of interest to dental surgeons. On the other hand, 33 findings in the dental region were highlighted. This demonstrates the need to evaluate cone-beam tomography in its entire volume. Figure 2 describes the number of incidental findings and the regions in which they were found.
Description of the quantity and location of the main incidental findings reported in the 41 articles surveyed.
DISCUSSION
CBCT and main incidental findings
CBCT images were well received in the dental community and became an instrument in the planning and management of patients. However, with the greater use of this technology, there was also an increase in the number of IFs. Allareddy et al. [66 Allareddy V, Vincent SD, Hellstein JW, Qian F, Smoker WR, Ruprecht A. Incidental findings on cone beam computed tomography images. Int J Dent. 2012;2012:871532. https://dx.doi.org/10.1155/2012/871532
https://doi.org/10.1155/2012/871532...
], Carter et al. [77 Carter L, Farman AG, Geist J, Scarfe WC, Angelopoulos C, Nair MK, et al. American Academy of Oral and Maxillofacial Radiology executive opinion statement on performing and interpreting diagnostic cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106(4):561-562. https://dx.doi.org/10.1016/j.tripleo.2008.07.007
https://doi.org/10.1016/j.tripleo.2008.0...
], and Horner et al. [88 Horner K, Islam M, Flygare L, Tsiklakis K, Whaites E. Basic principles for use of dental cone beam computed tomography: consensus guidelines of the European Academy of Dental and Maxillofacial Radiology. Dentomaxillofac Radiol. 2009;38(4):187-195. https://dx.doi.org/10.1259/dmfr/74941012
https://doi.org/10.1259/dmfr/74941012...
] warn that although often overlooked, the evaluation of all structures included in the examination is necessary according to the guidelines of the American and European Academies of Dentomaxillofacial Radiology. Furthermore, professionals should not only look at the area of interest, as they need to minimize the risk of neglecting hidden pathologies. The correct thing is to examine all the data in a systematic and regulated way [99 Miles DA, Danforth RA. Reporting findings in the cone beam computed tomography volume. Dent Clin North Am. 2014;58(3):687-709. https://dx.doi.org/10.1016/j.cden.2014.04.006
https://doi.org/10.1016/j.cden.2014.04.0...
].
It can be stated that one of the main parts of the tomography exam is the report. When faced with IFs, these should appear in the CBCT report. However, the inability to identify, inform or provide monitoring and care related to IFs can have adverse consequences for the patient and result in dentists neglecting their legal responsibility [44 Edwards R, Altalibi M, Flores-Mir C. The frequency and nature of incidental findings in cone-beam computed tomographic scans of the head and neck region: a systematic review. J Am Dent Assoc. 2013;144(2):161-170. https://dx.doi.org/10.14219/jada.archive.2013.0095
https://doi.org/10.14219/jada.archive.20...
,1010 Lopes IA, Tucunduva RM, Handem RH, Capelozza AL. Study of the frequency and location of incidental findings of the maxillofacial region in different fields of view in CBCT scans. Dentomaxillofac Radiol. 2017;46(1):20160215. https://dx.doi.org/10.1259/dmfr.20160215
https://doi.org/10.1259/dmfr.20160215...
].
Several studies indicate that IFs in several areas are prevalent. For example, in Pazera et al. [1111 Pazera P, Bornstein MM, Pazera A, Sendi P, Katsaros C. Incidental maxillary sinus findings in orthodontic patients: a radiographic analysis using cone-beam computed tomography (CBCT). Orthod Craniofac Res. 2011;14(1):17-24. https://dx.doi.org/10.1111/j.1601-6343.2010.01502.x
https://doi.org/10.1111/j.1601-6343.2010...
], three types of UA were diagnosed: thickening of the mucosa (23.7%), polypoid thickening of the mucosa (19.4%), and signs of acute sinusitis (3.6%). In the works by Rogers et al. [1212 Rogers SA, Drage N, Durning P. Incidental findings arising with cone beam computed tomography imaging of the orthodontic patient. Angle Orthod. 2011;81(2):350-355. https://dx.doi.org/10.2319/032210-165.1
https://doi.org/10.2319/032210-165.1...
]. AIs in the area of the airways included thickening of the mucosa (21.3%), deviation of the nasal septum (12.6%), concha hypertrophy (11.1%), bullous shell (3.9%) and retention cysts (2.9%).
Identifying an IF can save, but it can also lead to distress if the patient has not been warned that IFs may arise [1313 Friedlander AH, Bertolami CN. The ethics of managing incidental findings: Implications and challenges for the profession. JADA. 2014; 145(9):910-911. https://dx.doi.org/10.14219/jada.2014.38
https://doi.org/10.14219/jada.2014.38...
]. Togan et al. [1414 Togan B, Gander T, Lanzer M, Martin R, Lübbers HT. Incidence and frequency of nondental incidental findings on cone-beam computed tomography. J Craniomaxillofac Surg. 2016;44(9):1373-1380. https://dx.doi.org/10.1016/j.jcms.2016.06.026
https://doi.org/10.1016/j.jcms.2016.06.0...
] complement by highlighting that patients can be treated early by the right therapy to stop the progression of a disease.
The findings that require immediate interventions are soft tissue calcifications, such as arteries and ligaments, as there is a strong relationship between carotid artery calcification and risks for stroke [1515 Faxon DP, Creager MA, Smith SC Jr, Pasternak RC, Olin JW, Bettmann MA, et al. Atherosclerotic Vascular Disease Conference: Executive summary: Atherosclerotic Vascular Disease Conference proceeding for healthcare professionals from a special writing group of the American Heart Association. Circulation. 2004;109(21):2595-2604. https://dx.doi.org/10.1161/01.CIR.0000128517.52533.DB
https://doi.org/10.1161/01.CIR.000012851...
16 Bugnicourt JM, Chillon JM, Massy ZA, Canaple S, Lamy C, Deramond H, et al. High prevalence of intracranial artery calcification in stroke patients with CKD: a retrospective study. Clin J Am Soc Nephrol. 2009;4(2):284-290. https://dx.doi.org/10.2215/CJN.02140508
https://doi.org/10.2215/CJN.02140508...
-1717 Rennenberg RJ, Kessels AG, Schurgers LJ, van Engelshoven JM, de Leeuw PW, Kroon AA. Vascular calcifications as a marker of increased cardiovascular risk: a meta-analysis. Vasc Health Risk Manag. 2009;5(1):185-97. https://doi.org/10.2147/vhrm.s4822
https://doi.org/10.2147/vhrm.s4822...
]. Several studies were carried out to verify soft tissue calcifications, such as the one by Andò et al. [1818 Andò G, Tripodi R, Vizzari G, Trio O. Calcific Mönckeberg’s arteriosclerosis: an uncommon cause of radial access failure. Int J Cardiol. 2015;182:211-212. https://dx.doi.org/10.1016/j.ijcard.2015.01.002
https://doi.org/10.1016/j.ijcard.2015.01...
], Zain-Alabdeen et al. [1919 Zain-Alabdeen EH, El Khateeb SM. Incidental cone beam computed tomographic findings among Taibah University patients, KSA: A retrospective study. J Taibah Univ Med Sci. 2016;12(2):131-138. https://dx.doi.org/10.1016/j.jtumed.2016.10.014
https://doi.org/10.1016/j.jtumed.2016.10...
] e Khojastepour et al. [2020 Khojastepour L, Haghani J, Mirbeigi S. Incidental dentomaxillofacial findings on cone beam computed tomography images of Iranian population. JOHOE. 2014;3(1):12-15.]. The study by Silveira et al. [2121 Silveira HL, Damaskos S, Arús NA, Tsiklakis K, Berkhout EW. The presence of calcifications along the course of internal carotid artery in Greek and Brazilian populations: a comparative and retrospective cone beam CT data analysis. Oral Surg Oral Med Oral Pathol Oral Radiol. 2016;121(1):81-90. https://dx.doi.org/10.1016/j.oooo.2015.10.011
https://doi.org/10.1016/j.oooo.2015.10.0...
], described that extracranial calcifications were found in 136 patients (33.5%) of the 406 patients in their study. These more important IFs are expected in older patients. Even though most IFs are not lethal, they should not be ignored. Another important AI is Mönckeberg’s medial calcinosis, which can indicate kidney, heart problems, and diabetes. Unlike atherosclerosis, Mönckeberg’s medial calcinosis does not obstruct the vessel lumen. However, their elasticity and compliance decrease with a possible reduction of perfusion and clinically relevant coronary and peripheral arterial disease [1818 Andò G, Tripodi R, Vizzari G, Trio O. Calcific Mönckeberg’s arteriosclerosis: an uncommon cause of radial access failure. Int J Cardiol. 2015;182:211-212. https://dx.doi.org/10.1016/j.ijcard.2015.01.002
https://doi.org/10.1016/j.ijcard.2015.01...
], their early discovery may prevent limb amputations. However, most IFs do not require treatment or referral to another professional [1010 Lopes IA, Tucunduva RM, Handem RH, Capelozza AL. Study of the frequency and location of incidental findings of the maxillofacial region in different fields of view in CBCT scans. Dentomaxillofac Radiol. 2017;46(1):20160215. https://dx.doi.org/10.1259/dmfr.20160215
https://doi.org/10.1259/dmfr.20160215...
].
The literature demonstrates that these IFs have a varied frequency [1919 Zain-Alabdeen EH, El Khateeb SM. Incidental cone beam computed tomographic findings among Taibah University patients, KSA: A retrospective study. J Taibah Univ Med Sci. 2016;12(2):131-138. https://dx.doi.org/10.1016/j.jtumed.2016.10.014
https://doi.org/10.1016/j.jtumed.2016.10...
]. However, most of these findings do not cause serious harm to patients, however, an examination should not be neglected. The study by Khojastepour and collaborators [2020 Khojastepour L, Haghani J, Mirbeigi S. Incidental dentomaxillofacial findings on cone beam computed tomography images of Iranian population. JOHOE. 2014;3(1):12-15.] concluded that all images of CBCTs need to be reviewed comprehensively, since their study, 475 of 773 individuals had at least one AI, with an overall rate of these findings of 60%. This is in line with the study by Çaglayan and Tozoglu [33 Cağlayan F, Tozoğlu U. Incidental findings in the maxillofacial region detected by cone beam CT. Diagn Interv Radiol. 2012;18(2):159-163. https://dx.doi.org/10.4261/1305-3825.DIR.4341-11.2
https://doi.org/10.4261/1305-3825.DIR.43...
], which showed that the frequency of incidental findings was 92.8% in 207 patients. These discrepancies may be due to variations in age groups, patient characteristics, ethnicity, socioeconomic aspects, and anatomical groupings [1919 Zain-Alabdeen EH, El Khateeb SM. Incidental cone beam computed tomographic findings among Taibah University patients, KSA: A retrospective study. J Taibah Univ Med Sci. 2016;12(2):131-138. https://dx.doi.org/10.1016/j.jtumed.2016.10.014
https://doi.org/10.1016/j.jtumed.2016.10...
].
Note that the largest number of AIs occurs in areas where the DC is not commonly familiar. This means that some AIs may go unnoticed, such as calcifications of the hyoid-style process, which may suggest Eagle’s syndrome. However, tonsilloliths, although not serious, can cause daily problems such as decreased social interaction due to halitosis. In these cases, where the AI can be harmful to the patient, referral to other professionals is necessary.
Most of the authors have dedicated themselves to researching AIs and their impacts. The findings that require immediate interventions are soft tissue calcifications, as reported by Faxon et al. [1515 Faxon DP, Creager MA, Smith SC Jr, Pasternak RC, Olin JW, Bettmann MA, et al. Atherosclerotic Vascular Disease Conference: Executive summary: Atherosclerotic Vascular Disease Conference proceeding for healthcare professionals from a special writing group of the American Heart Association. Circulation. 2004;109(21):2595-2604. https://dx.doi.org/10.1161/01.CIR.0000128517.52533.DB
https://doi.org/10.1161/01.CIR.000012851...
] when highlighting that there is evidence about the strong association between intracranial artery calcification and carotid artery stenosis, with better defined vascular risk factors for stroke (stroke). An association was also found between the presence of calcifications in any artery and a three to four times greater risk of cardiovascular events and death. It is even known that in the context of atherosclerosis, carotid artery disease identifies patients with a higher risk of fatal and non-fatal myocardial infarction and stroke [1515 Faxon DP, Creager MA, Smith SC Jr, Pasternak RC, Olin JW, Bettmann MA, et al. Atherosclerotic Vascular Disease Conference: Executive summary: Atherosclerotic Vascular Disease Conference proceeding for healthcare professionals from a special writing group of the American Heart Association. Circulation. 2004;109(21):2595-2604. https://dx.doi.org/10.1161/01.CIR.0000128517.52533.DB
https://doi.org/10.1161/01.CIR.000012851...
].
Although they are frequent, it is not yet known what the precise incidence of IFs is in the literature [1919 Zain-Alabdeen EH, El Khateeb SM. Incidental cone beam computed tomographic findings among Taibah University patients, KSA: A retrospective study. J Taibah Univ Med Sci. 2016;12(2):131-138. https://dx.doi.org/10.1016/j.jtumed.2016.10.014
https://doi.org/10.1016/j.jtumed.2016.10...
]. However, most of them do not appear to cause harm to patients and, therefore, do not require any intervention [1010 Lopes IA, Tucunduva RM, Handem RH, Capelozza AL. Study of the frequency and location of incidental findings of the maxillofacial region in different fields of view in CBCT scans. Dentomaxillofac Radiol. 2017;46(1):20160215. https://dx.doi.org/10.1259/dmfr.20160215
https://doi.org/10.1259/dmfr.20160215...
]. Finally, the low number of IFs that threaten patients’ lives emphasizes that CBCT should not be considered a replacement for ordinary radiographs, given that its radiation dose is higher when compared to two-dimensional radiographs and its cost is high, but if it is used, all areas of the scan must be evaluated by an experienced radiologist or dentist [2222 Dief S, Veitz-Keenan A, Amintavakoli N, McGowan R. A systematic review on incidental findings in cone beam computed tomography (CBCT) scans. Dentomaxillofac Radiol. 2019;48(7):20180396. https://dx.doi.org/10.1259/dmfr.20180396
https://doi.org/10.1259/dmfr.20180396...
].
Impact of IFs on patient’s lives
IFs can be due to several factors, such as allergies, anatomical variations, or even the first signs of serious diseases [1515 Faxon DP, Creager MA, Smith SC Jr, Pasternak RC, Olin JW, Bettmann MA, et al. Atherosclerotic Vascular Disease Conference: Executive summary: Atherosclerotic Vascular Disease Conference proceeding for healthcare professionals from a special writing group of the American Heart Association. Circulation. 2004;109(21):2595-2604. https://dx.doi.org/10.1161/01.CIR.0000128517.52533.DB
https://doi.org/10.1161/01.CIR.000012851...
,2323 Oliveira RS, Peretto JT, Panzarella FK, Raitz R. Evaluation of Incidental Findings on Cone Beam Computed Tomography. Pesqui Bras Odontopediatria Clín Integr. 2019;19:e4340. https://dx.doi.org/10.4034/pboci.2019.191.81
https://doi.org/10.4034/pboci.2019.191.8...
]. Underdiagnosis can be of concern since not identifying or ignoring an IF can cause harm to the patient. Not infrequently, the CD is the first professional to find signs of diseases whose health directly reflects on the individual’s life, such as calcifications of the carotid artery, which several studies indicate as a stroke and stroke predictor. The discovery of these IFs can help the professional to recognize significant entities and, at the same time, reduce the patient’s exposure to other unnecessary exams, which can cause economic, psychological, and physical consequences [1919 Zain-Alabdeen EH, El Khateeb SM. Incidental cone beam computed tomographic findings among Taibah University patients, KSA: A retrospective study. J Taibah Univ Med Sci. 2016;12(2):131-138. https://dx.doi.org/10.1016/j.jtumed.2016.10.014
https://doi.org/10.1016/j.jtumed.2016.10...
,2424 Doğramacı EJ, Rossi-Fedele G, McDonald F. Clinical importance of incidental findings reported on small-volume dental cone beam computed tomography scans focused on impacted maxillary canine teeth. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014;118(6):e205-e209. https://dx.doi.org/10.1016/j.oooo.2014.09.006
https://doi.org/10.1016/j.oooo.2014.09.0...
].
The impacts on patients’ lives can occur due to three factors, which are: the correct diagnosis, clear and transparent information, and the early detection of potentially serious AIs. Knowing them helps the clinician in the management of each case, as well as making treatment faster and more efficient, less costly, and protecting the lives of patients.
Diagnostic accuracy is the key to preventing further harm to patients. A properly observed AI eliminates further investigation of potentially harmless entities. The overestimated diagnosis can give the patient the impression of being in danger and make him go through situations of stress and unnecessary torment. Authors such as Doğramacı and collaborators [2424 Doğramacı EJ, Rossi-Fedele G, McDonald F. Clinical importance of incidental findings reported on small-volume dental cone beam computed tomography scans focused on impacted maxillary canine teeth. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014;118(6):e205-e209. https://dx.doi.org/10.1016/j.oooo.2014.09.006
https://doi.org/10.1016/j.oooo.2014.09.0...
] and Husain et al. [2525 Husain MA, Tetradis S, Mallya SM. Intraosseous pneumatocysts of the cervical spine: a report of four cases and review of literature. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014;119(1):49-54. https://dx.doi.org/10.1016/j.oooo.2014.09.019
https://doi.org/10.1016/j.oooo.2014.09.0...
] affirm that the differentiation between important and non-clinical findings reduces referrals to other complementary exams, such as biopsies. However, underdiagnosis is also dangerous. The dentist who requests CBCT exams for his patient should examine them for IFs for the benefit of the patient’s health, ensuring that an efficient procedure is performed [2222 Dief S, Veitz-Keenan A, Amintavakoli N, McGowan R. A systematic review on incidental findings in cone beam computed tomography (CBCT) scans. Dentomaxillofac Radiol. 2019;48(7):20180396. https://dx.doi.org/10.1259/dmfr.20180396
https://doi.org/10.1259/dmfr.20180396...
].
In the studied literature, there is a duality in terms of informing or not patients about all the IFs found in the exams. At one end, there are those who argue that findings that do not interfere with health and well-being should be omitted and others who say that the patient has the right to know everything that was found in his CBCT. Welch and colleagues [2626 Welch H, Gilbert W, Steven S, Lisa M. Overdiagnosed: making people sick in the pursuit of health. Boston: Beacon Press; 2011.], ratify this dilemma by pointing out that on the one hand, there is the concept that too much information is potentially harmful and that the patient would be better off without knowing all the AIs. On the other hand, the Council of the American Medical Association on Ethical and Judicial Affairs [2727 American Medical Association Journal of Ethics. The AMA Code of Medical Ethics’ Opinions on Informing Patients Opinion 8.08 - Informed Consent. Amn Med Assoc J Ethics. 2012;14(7):555-556. https://dx.doi.org/10.1001/virtualmentor.2012.14.7.coet1-1207
https://doi.org/10.1001/virtualmentor.20...
], says that professionals have an ethical and legal duty to disclose all relevant information to patients. Scarfe [2828 Scarfe WC. Incidental findings on cone beam computed tomographic images: a Pandora’s box? Oral Surg Oral Med Oral Pathol Oral Radiol. 2014;117(5):537-540. https://dx.doi.org/10.1016/j.oooo.2014.01.002
https://doi.org/10.1016/j.oooo.2014.01.0...
] adds by stating that the patient’s “right to know” outweighs all other professional considerations and that, ultimately, it is up to the patient to decide how much risk he himself must tolerate.
Seeking a consensus in this area, what should be done is to dialogue with the patient, explaining the possible IFs that can be found in the area where the exam is performed, seeking to exhaust all the patient’s doubts. The conceptualized consent process includes a discussion of whether and how the patient wishes to be informed of any clinically significant findings that may require further studies or interventions to ensure their health and well-being [2929 Friedlander AH, Bertolami CN. The ethics of managing incidental findings: Implications and challenges for the profession. JADA. 2014; 145(9):910-911. https://dx.doi.org/10.14219/jada.2014.38
https://doi.org/10.14219/jada.2014.38...
]. When dentists anticipate these possibilities and communicate with their patients in this shared decision-making process, AIs are likely to be managed in a manner that satisfactorily meets the patient’s wishes [2929 Friedlander AH, Bertolami CN. The ethics of managing incidental findings: Implications and challenges for the profession. JADA. 2014; 145(9):910-911. https://dx.doi.org/10.14219/jada.2014.38
https://doi.org/10.14219/jada.2014.38...
]. In this sense, it is necessary to resolve doubts about the CBCT and the IFs, managing these findings in the best possible way.
CONCLUSION
The main IFs found in the bone / TMJ region, were 35 entities, on which the most frequent were the bifid mandibular condyle and fibrous dysplasia. Then the dental region, where 33 IFs were found, on which the most frequent were the supernumerary teeth and impacted teeth. The airway region and soft tissue calcifications showed 14 IFs each. In the first, mucosa thickening and mucosal retention cysts stand out. In soft tissue calcifications, on the other hand, tonsillitis and hyoid-style ligament calcifications were the most reported. Finally, in the group of other findings, 5 different IFs were found.
These IFs have variable frequencies due to several factors. Most of them do not affect the patient’s life. However, a small portion requires immediate intervention, such as soft tissue calcifications, which are generally associated with older patients and are closely linked to cardiovascular diseases. Finally, more than half of the studies pointed out that the IFs are located in an extragnatic region. Therefore, it is necessary to evaluate the entire volume of data from the CBCT exam.
How to cite this article
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Souza DL, Ramos MEE, Corrêa M. Main incidental findings from cone beam computed tomography in the head and neck region and the impact in patients’ lives: an integrative literature review. RGO, Rev Gaúch Odontol. 2022;70:e20220047. http://dx.doi.org/10.1590/1981-86372022004720200091
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Appendix
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Publication Dates
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Publication in this collection
04 Nov 2022 -
Date of issue
2022
History
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Received
16 June 2020 -
Reviewed
25 Jan 2021 -
Accepted
26 Apr 2021