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Cukurova Medical Journal
Can Intra Oral Periapical Radiographs be Used as an
Adjunct Diagnostic Marker in Detecting Underlying
Systemic Diseases? A Randomised Case Control Study’
İntra Oral Periapikal Dental Radyografiler Altta Yatan Sistematik Hastalıkların
Tespitinde Yardımcı Diagonostik Markerlar Olarak Kullanılabilir mi?- Randomize
Edilmiş Vaka Kontrol Çalışması
Renita Lorina Castelino1, Subhas Babu1, Shishir Ram Shetty1, Anusha Rangare Laxmana2,
Preethi Balan1, Fazıl Ka1
1Nitte University, Oral Medicine And Radiology, Mangalore Karnataka, INDIA.
2Department of Oral Medicine and Radiology Century International Institute Of Dental Sciences And Research
Centre Poinachy Kasargod .
Cukurova Medical Journal 2015;40(4):661-669.
ABSTRACT
Purpose: Periapical dental radiography, despite being two dimensional and limited in size appears to be the best
projection to identify the nutrient canals in the mandibular anterior region. A study was undertaken to evaluate the
presence of mandibular nutrient canals in the anterior region using intra oral periapical films in subjects with
hypertension, diabetes mellitus, completely and partially edentulous mandible, periodontally compromised subjects and
in post menopausal women and was compared with controls.
Material and Method: The study consisted of seven groups each with 50 subjects. The radiographic analysis of the
anterior mandible was done using the intra oral periapical radiographs and the presence or absence of nutrient canals
was evaluated.
Results: A statistical increase in the prevalence of nutrient canals was observed in all the study groups. The nutrient
canals were present in 8% in the control group, 34 % in the hypertensive group, 60% in the diabetes group, 72% in
subjects with both diabetes and hypertension, 70% in completely and partially edentulous patients, 62 % in the
periodontitis group and 50% in the post menopausal women.
Conclusion: The presence of nutrient canals can be used as an adjunct diagnostic marker for detection of underlying
systemic diseases.
Key words: Nutrient,diabetes, dental.
ÖZET
Amaç: Periapikal dental radyografi , iki boyutlu ve boyutun sınırlı olmasına rağmen, alt çenenin ön bölgesindeki besin
kanallarını belirlemek için en iyi projeksiyon tipi olarak görülür. Çalışma; hipertansiyona , diabetes mellitus a, tamamen
ve kısmen dişsiz alt çeneye sahip kişilerde, periodontal olarak risk taşıyan hastalarda ve menopoz sonrası kadınlarda
intraoral periapikal filmler kullanılarak ön bölgedeki mandibular besin kanallarının varlığını ölçmeyi hedeflemiştir ve
sonuçlar kontrollerle kıyaslanmıştır.
Materyal ve metod: Çalışma her biri 50 deneği içeren 7 gruptan oluşmuştur. Anterior mandibulanın radyografik analizi
intra oral periapikal radyografiler kullanılarak yapıldı ve besin kanalların varlığı veya yokluğu değerlendirildi .
Araştırma Makalesi / Research Article
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Bulgular: Besin kanalların prevalansındaki istatistiksel artış , tüm çalışma gruplarında gözlendi. Besin kanalları kontrol
grubunun % 8' inde , hipertansif grubun % 34' ünde , diyabet grubu'nun % 60'ında , hem diyabeti hem de hipertansiyonu
olan hastaların % 72'sinde, tamamen ya da kısmen dişsiz hastaların % 70'inde , periodontitis grubun % 62'sinde ve
menopoz sonrası kadınların % 50'sinde bulunmaktadır.
Sonuç: Besin kanallarının varlığı, altta yatan sistematik hastalıkların tespiti için yardımcı tanı belirteci olarak
kullanılabilir.
Anahtar kelimeler: Besin, Diyabet, Diş
INTRODUCTION
Intraoral radiography is undoubtedly the
backbone of dental radiology. It has a key role in
arriving at a confirmed diagnosis following clinical
examination. Although the oral physicians are well
versed with the normal anatomy, slight variations
may highlight unrecognized systemic disorders.
For example, loss of lamina dura in absence of any
dental pathology may be taken as normal, but can
be a manifestation of hyperparathyroidism,
widening of periodontal membrane space without
dental pathology may be indicative of a condition
like scleroderma. Similarly the presence of another
landmark namely nutrient canal has been
correlated with various systemic diseases over a
period of time which can be of clinical significance
if thoroughly evaluated. Nutrient canals are spaces
in bones and are considered to be channels that
contain blood vessels and nerves1. They are
frequently seen as fine linear, curvilinear or circular
radiolucencies situated interproximally within the
alveolar bone and inferior to the tooth roots.
They appear most frequently in the intra oral
periapical radiographs of the mandibular anterior
region, followed by the premolar region, the
maxillary premolar area and the wall of the
maxillary sinus. They have a vertical rather than a
horizontal direction2. Nutrient canals were first
described by Hirschfeld in 1923 and are also called
interdental canals3.
Many authors have interpreted nutrient canals
as a diagnostic sign in confirming calcium
deficiency. Some consider nutrient canals as
normal structures, whereas others have correlated
the radiographic appearance of nutrient canals
with hypertension, diabetes mellitus, periodontal
disease, rickets, calcium deficiency and disuse
atrophy. The questions regarding the clinical
significance and relationship between the
presence of nutrient canals and various
pathologies remain unanswered and it is not clear
why they appear in some and not in others.
Therefore, the purpose of the study was to
evaluate the presence of nutrient canals in the
intra oral periapical radiographs of the mandibular
anterior region, thereby correlating their presence
with a variety of disease states like hypertension,
diabetes, periodontitits and partially and
completely edentulous arches and physiological
state like menopause and comparing them with the
control group.
MATERIALS and METHOD
The present study is a randomized case
control study conducted on subjects reporting to
the Department of Oral Medicine and Maxillofacial
Radiology. The study sample consisted of 350
subjects divided into 7 equal groups of 50 patients
each of either gender, between the ages of 20
years to 70 years.
The groups were:
Control Group 1: Healthy subjects without any
systemic and oral diseases.
Group 2: Subjects diagnosed with hypertension
with blood pressure more than or equivalent to
140/90 mm of Hg or and who are on medication.
Group 3: Subjects diagnosed with Type 2 diabetes
confirmed with random blood sugar estimation
more than or equivalent to 200 mg/dl or who are
on medication.
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Group 4: Subjects diagnosed with both Type 2
diabetes and hypertension or as who are on
medication. .
Group 5: Healthy subjects with bilaterally missing
lower posterior teeth (partially edentulous) and
completely edentulous
Group 6: Subjects with probing depth more than or
equivalent to 4 mm and clinical attachment loss
more than or equivalent to 2 mm.
Group 7: Post menopausal women above 45
years of age.
Written informed consent was obtained from
each patient after the aims and methodology of the
study was explained. In a case history performa,
detailed history was recorded for each subject and
thorough oral examination was performed for all
the subjects.
I) Clinical Examination
Selected individuals were clinically evaluated
by making the patients sit comfortably on a dental
chair. Blood pressure was measured with
stethoscope and sphygmomanometer by
auscultatory method preceded by palpatory
method. Random blood sugar levels were
measured using GOD-POD method.
II) Radiographic Procedure
Dental intraoral x-ray machine (SATELEC)
with 70 kvP and 8 mA and an exposure time of
0.4-0.8 seconds which was provided with a total
filtration of 2mm aluminum equivalent was used in
the study.
The mandibular anterior region was selected
as the site of study due to higher frequency of
occurrence of nutrient canals in this region. The
patients were seated comfortably on a
conventional dental chair and intraoral
radiographic procedure was done by using
paralleling cone technique as described by White
SC, Pharoah MJ. XCP film holding instrument was
used to position the film in position. A long 16 inch
target film distance was used to compensate for
the image magnification. After proper adjustment
of the angulations, the films were exposed for
appropriate time that was set on the timer. The
edentulous patients were instructed to remove all
non-fixed prostheses from the mouth before the
radiographic procedure.
III) Processing of the Exposed Films
The films were then processed by the automatic
processor (Durr periomat).
IV) Interpretation of Radiographs
Interpretation of radiographs was carried out
with the help of radiographic viewer and a
magnifying lens. The radiographs were evaluated
for the presence or absence of radiolucent lines
running vertically either in interdental area or in the
periapical region.
All the radiographs were evaluated by two
inter examiners [‘1’ and‘2’], if any conflict was
detected between the findings of the radiographs a
third inter examiner was introduced [‘3’]. The
observations were then entered in the proforma
from which master charts were prepared.
Data obtained were analyzed using Tukeys
test for multiple comparisons between the groups,
Chi- Square Test for comparison of individual study
group to the control group and ANOVA test for
gender matching using SPSS version 18 software.
RESULTS
108 subjects (60.7%) had the presence of
nutrient canals who were above 50 years of age
and the least was found in 11 subjects(6.2%) who
were under 30 years of age (Graph 1).
Out of 350 subjects, 167 were males and 183
were females. Nutrient canals were present in 100
male subjects (59.88%) and in 78 female subjects
(42.62%). There was a statistically significant
increase in the occurrence of nutrient canals
among the male subjects compared to female
subjects. (p= 0.001) (Graph 2).
A statistically significant increase in the
presence of nutrient canals in group 2, 3 subjects
was observed when compared to subjects of group
1. (p= 0.001)
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A statistically significant increase in the
presence of nutrient canals in subjects of group 4
was observed when compared to subjects of group
1. (p= 0.001) When the prevalence of nutrient
canals in group 2 (hypertensive) (34%) was
compared to group 4 (72%) (both hypertensive and
diabetic),a statistically very highly significant
difference was observed [p‹ 0.001] .Similarly on
multiple comparisons, group 4 showed a
statistically very highly significant increase in the
presence of nutrient canals when compared to
group 3 (diabetic) (60%) [p‹ 0.001]. (Graph 3)
A statistically significant increase in the
presence of nutrient canals in group 5 subjects
was observed when compared to subjects of
group1 subjects. (p= 0.001)
When an inter comparison was made
between completely and partially edentulous
group, a statistically significant difference was
observed. (p= 0.001) A statistically significant
increase in the presence of nutrient canals in
group 6 subjects was observed when compared to
subjects of group 1. (p= 0.001)( Graph 4)
A statistically significant increase in the
presence of nutrient canals in group 7 was
observed when compared to subjects of group 1.
(p= 0.001)
Figure.1. Overall Age Wise Distribution of Nutrient Canals
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Figure 2. Overall Gender Wise Prevalence Of Nutrient Canals In Study Groups
Figure.3. Prevalence of Nutrient Canals Between the Groups.
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Figure. 4. Comparison of The Presence of Nutrient Canals Between Completely and Partially
Edentulous Subjects.
DISCUSSION
Nutrient canals are frequently observed in the
dental periapical radiographs, and they are
considered to serve as conduits for blood vessels
and nerves4. The predominance of nutrient canals
in the anterior region is attributed to a thin alveolar
process, horizontally arranged trabeculae and
decreased bony support of cortical and cancellous
bone which is more prone to irritation from calculus
and trauma1. Of all the anatomic landmarks
encountered on radiographic examination, nutrient
canals remain the most enigmatic in their presence
as well as absence1. Very few studies on nutrient
canals have been conducted in Indian population
when compared to studies undertaken on western
population.
In the present study, the prevalence of
nutrient canals was increased in the age group >50
years, which was in accordance with studies
carried out by Reddy VG et al1. The possible
factors for the increase in the nutrient canals can
be attributed to edentulism, periodontitis,
hypertension, diabetes mellitus etc. In the present
study higher prevalence of NC was observed in
males which was in accordance with studies
carried out by Patel JR et al2, Pierrakou ED et al5
and Patsakas AJ et al6 .
According to a study conducted by Greer DF
et al 1968 7, nutrient canals appear on 5% of
routine intraoral radiographs. In the present study
nutrient canals were present in 8% of control
group. The nutrient canals are considered as a
normal anatomical landmark in radiographic
examination and it is not clear why they appear in
some and not in others. The results of the present
study were also in agreement with the majority of
studies which reported an increased prevalence of
nutrient canals in hypertensive subjects which
could be due to dilatation of arterioles, hypertrophy
and hyperplasia of the vessel wall, and
arteriosclerosis, along with thickening of the arterial
wall. There is narrowing of the lumen which may
lead to the opening of more collateral blood
vessels to compensate for the diminishing blood
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supply. All these changes contribute to the
increased presence of nutrient canals in
hypertensive patients1,8
In the present study the prevalence of nutrient
canals was more in the diabetes group which was
in accordance with studies carried out by Pierrakou
et al 5 and Reddy VG et al 1 They also reported
that the recent blood glucose value and duration of
disease has significant effect on the prevalence of
nutrient canals. The reason postulated for the
increase of nutrient canals in the diabetic group
could be attributed to the deficiency of insulin
having mitogenic action on endothelial cells which
would lead to collateral vessel formation. The
process of atherosclerosis can also be seen
leading to narrowing of blood vessel lumen.
Therefore, this collateral vessel formation may act
as a compensatory mechanism which leads to
increased prevalence of nutrient canals1.
In the present study, an increased prevalence
of nutrient canals was observed in patients with
both diabetes and hypertension when compared to
prevalence of nutrient canals in patients with only
diabetes or only hypertension. None of the studies
reported so far have evaluated the presence of
nutrient canals in the patients with diabetes
mellitus and hypertension. Since both the disease
entities can cause alterations in vasculature and
formation of collaterals their simultaneous
presence may have probably caused the increase
in the prevalence of nutrient canals.
In the present study, an increased prevalence
of nutrient canals was observed in partially
edentulous patients when compared to the control
group which was in agreement with the study
conducted by Kishi et al 9 who observed that the
patients with a higher rate of mandibular molar loss
were associated with the appearance of nutrient
canals in the anterior mandible. The association
between the loss of molars and the appearance of
nutrient canals in the anterior mandible suggests
that a shift in the occlusal stress towards the
anterior teeth may have some effect on the
osseous pattern.
Besides this, the present study also evaluated
patients with completely edentulous. An increased
prevalence of nutrient canals was observed in
completely edentulous patients when compared to
partially edentulous patients. This was in
agreement with studies carried out by Bilge OM et
al10 and Kishi et al9. Wood NK et al11 reported that
nutrient canals appear much more pronounced on
intra oral periapical radiographs when the teeth are
missing. The anatomic structure of the anterior
mandible in edentulous patients is quite different
from that of dentulous patients. The higher
incidence of nutrient canals in edentulous persons
may be associated with resorption of the alveolar
bone following tooth loss and the thickness of the
remaining alveolar bone. The knowledge of the
anatomy of the nutrient canals in edentulous
patients would be useful as they contain blood
vessels which could be a potential bleeding point
during any minor surgical procedure carried out in
the mandibular anterior region. The presence of
nutrient canals also indicates a thin ridge which is
useful in implant assessment12 . In the present
study, an increased prevalence of nutrient canals
was also observed in periodontally compromised
patients with bone loss which was in accordance
with the studies carried out by Patel JR et al2 and
Kishi et al9. The incidence of nutrient canals and
the number of observable canals increased as the
evidence of bone resorption became more severe.
The presence of nutrient canals appears to be
associated with the presence of periodontal
disease that brings about sclerotic changes in the
trabecular bone pattern. They also appear more
pronounced due to the ability of radiographs to
record the thinner bony structures clearly1.
Hirschfeld3 interpreted nutrient canals as a
diagnostic sign in confirming calcium deficiency but
later, in 1927, said that it was a normal entity.
Some authors have also considered nutrient
canals as a diagnostic sign in confirming calcium
deficiency2. In the study reported here, post
menopausal women were also evaluated for the
presence of nutrient canals. A higher prevalence
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Cukurova Medical Journal
was observed in the post menopausal group when
compared to the control group. This may probably
be due to calcium deficiency in post menopausal
women. However, in the present study
confirmatory bone densitometry test was not
conducted to detect for calcium deficiency, hence
the presence of nutrient canals cannot be
considered as a confirmatory finding in the study.
The present study lays down a hypothesis that the
presence of nutrient canals could be used as a
radiographic diagnostic sign in confirming calcium
deficiency following bone densitometry test which
is mandatory.
Thus the study revealed that nutrient canals in
the mandibular anterior region were increased in
the subjects with hypertension, diabetes mellitus,
completely and partially edentulous subjects,
periodontally compromised subjects and in post
menopausal women.
Finally, as there was an increase in the
prevalence of nutrient canals in the systemic
diseases like hypertension and diabetes, a larger
sample of individual groups is needed to have an
in depth knowledge of the small variations
according to duration and frequency which might
help in arriving at better diagnosis and for better
treatment planning. The findings of this study could
be used as a radiographic diagnostic marker for
further investigations so as to bring forth the
underlying systemic conditions.
CONCLUSION
The statistically significant findings from this
study can be used to recommend that the
presence of nutrient canals can act as an adjunct
diagnostic marker for detection of underlying
systemic diseases like diabetes mellitus,
hypertension etc. Further confirmation and
evaluation of the patient by referral to general
physician will benefit the patient in long term and
also add a new dimension in the diagnosis of
underlying systemic condition. The present study
also laid down a hypothesis that the presence of
nutrient canals in post menopausal women can be
suspected as a sign of calcium deficiency.
REFERENCES
1. Reddy VG, Ali IM, Shashikanth MC. An intraoral
periapical radiographic study of nutrient canals as a
diagnostic aid in systemic diseases and pathological
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2. Patel JR Wuehrmann AH. A radiographic study of
nutrient canals. Oral Surgery Oral Med Oral Pathol.
1976;42:693-701.
3. Hirschfeld I. A study of skulls in the American
museum of natural history in relation to periodontal
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4. Jaju PP, Suvarna PV, Parikh NJ. Incidence of
mandibular nutrient canals in hypertensive patients: A
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5. Pierrakou ED, Donta CN The nutrient canals.
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region in diabetic patients. Odontostomatol Proodos.
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6. Patsakas AJ, Donta CN. Incidence of nutrient canals
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1990;34:41-6.
7. Greer DF, Wege WR, Wuehrmann A H; The
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9. Kishi K, Nagaoka T, Gotoh T, Imai K, Fujiki Y.
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Oral Surg Oral Med Oral Pathol 1982;54:118-22.
10. Bilge OM, Harorli AB, Yilmaz AB. Radiographic
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12. White SC, Pharaoh MJ, editors. Oral radiology,
Principles and interpretations. 6th ed St.Louis:
Mosby. 2010;111-2
.
Yazışma Adresi / Address for Correspondence:
Dr. Renita Lorina Castelino
Nitte University
Oral Medicine and Radiology
Mangalore, Karnataka, INDIA
E-mail: renita.castelino@yahoo.com
Geliş tarihi/Received on : 06.12.2014
Kabul tarihi/Accepted on: 23.01.2015
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