Table of Contents  
Year : 2022  |  Volume : 14  |  Issue : 2  |  Page : 79-80

Diabetes, Chronic Kidney Disease, Hypertension, and Tram-Track Vessels − A Vicious Chain

1 Department of Clinic and Oral & Maxillofacial Radiology, Case Western Reserve University School of DentalMedicine, Cleveland, Ohio, USA
2 Professor and Director of Radiology, University of Pennsylvania School of Dental Medicine, Philadelphia, PA 19460, USA

Date of Submission03-Nov-2022
Date of Acceptance04-Nov-2022
Date of Web Publication10-Jan-2023

Correspondence Address:
Ali Z Syed
Department of Clinic and Oral & Maxillofacial Radiology, Case Western Reserve University School of Dental Medicine, Cleveland, Ohio
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jofs.jofs_268_22

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How to cite this article:
Syed AZ, Mupparapu M. Diabetes, Chronic Kidney Disease, Hypertension, and Tram-Track Vessels − A Vicious Chain. J Orofac Sci 2022;14:79-80

How to cite this URL:
Syed AZ, Mupparapu M. Diabetes, Chronic Kidney Disease, Hypertension, and Tram-Track Vessels − A Vicious Chain. J Orofac Sci [serial online] 2022 [cited 2023 Jun 8];14:79-80. Available from:

Monckeberg medial arteriosclerosis (MAA) is a relatively unexplored systemic condition, especially in oral and maxillofacial imaging, presenting as an asymptomatic incidental finding—"tram-track vessels." This type of arteriosclerosis is noted in conditions such as diabetes and chronic kidney disease. It imperative for us to alert the clinician for appropriate diagnosis and management when noted.[1]

Dental health professionals caring for patients with kidney diseases should be careful while prescribing medications since most of them are metabolized and excreted through the kidneys. Appropriate knowledge about subtle radiographic features may assist the clinician in diagnosing and managing the patient. Diabetes, over time, leads to microvascular damage and damage to nephrons that will eventually progress to chronic kidney disease. Untreated diabetes may also predispose to high blood pressure, damaging kidney function. High cholesterol content in the blood leads to the precipitation of calcium salts within the tunica media of the blood vessel walls, leading to linear calcifications, making the blood vessels less elastic and more rigid, and decreasing end-organ perfusion. Many such patients end up having limb amputations. Cardiovascular disease is also highly prevalent among the same cohort of the population. Hence this is a significant and often neglected chain of health events since they are silent and asymptomatic until a more advanced stage. Vascular tram-track calcifications must alert the dental professional to get a full-blown medical evaluation for underlying systemic pathology.

Imaging plays an essential in the diagnosis in the diagnosis of tram-track vessels. In the United States, approximately 15 million panoramic radiographs and 5 million Cone beam computed tomographic volumes are performed for dental evaluation. Vascular calcifications can be diagnosed using intraoral, panoramic, and cone-beam computed tomography. Although many of the calcifications may be subtle at first, in more advanced stages of calcification, they are noted as tram-track calcification of the external carotid, internal carotid, and their branches. Monckberg first described this condition in 1903. Syed et al. found that the prevalence of MMA was 6.2% and correlated with kidney disease.[2] Several imaging modalities are used to identify vascular calcifications, such as ultrasound, plain radiography, Computed Tomography (CT), Cone Beam Computed Tomography (CBCT), and Magnetic Resonance Imaging (MRI).

Cardiovascular disease is the leading cause of death in many countries, especially India. In a study by Huffman et al. published in the journal of the American College of Cardiology, the average annual number of deaths in India was projected to be 4.77 million by 2020 from 2.26 million in 1990.[3] Moreover, aging and certain systemic conditions could contribute to the deposition of calcium in the different layers of the blood vessels. Vascular calcifications may be broadly classified into arterial and venous calcifications. Arterial calcifications are further classified into atherosclerosis and arteriosclerosis. Atherosclerosis is calcific deposition in the intimal layer leading to plaque accumulation within the vessel lumen, predisposing to cerebrovascular events like a stroke or cardiovascular events like myocardial infarction.

On the other hand, if the calcified material is noted in the tunica media, it is referred to as Monckeberg medial arteriosclerosis, also known as medial arterial calcification (MAC). Phleboliths are common findings in the pelvic veins. Preventing diabetes and preventing kidney disease by monitoring and treating diabetes is the first step. Keeping cholesterol under control and preventing high blood pressure with good dietary habits and exercise will break this vicious chain of events would prevent chronic kidney disease. These vascular calcifications are an alerting mechanism if the underlying systemic conditions are not adequately diagnosed or managed.

Identifying tram-track vascular calcifications may be a critical factor in determining and managing significant systemic pathology related to diabetes, hypertension, and chronic kidney disease. Regular visits to primary care physicians and, referral to medical specialists is the key to preventing the ravages of diabetes in our patient population. Dental healthcare providers play a vital role in this process.

  References Top

Shahid K, Weng S, Cook L, Syed AZ. Detection of monckeberg medial sclerosis on conventional dental imaging. J Mich Dent Assoc 2017;99:40-69.  Back to cited text no. 1
Syed AZ, Xu Y, Alluri LS, Jadallah B, Mendes RA, Pinto A. Mönckeberg’s medial arteriosclerosis in the oral and maxillofacial region: A pilot study. Oral Dis 2022. doi: 10.1111/odi.14393.  Back to cited text no. 2
Huffman MD, Prabhakaran D, Osmond C et al. New Delhi Birth Cohort. Incidence of cardiovascular risk factors in an Indian urban cohort results from the New Delhi birth cohort. J Am Coll Cardiol 2011;57:1765-74.  Back to cited text no. 3


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