The utility of panoramic imaging of the temporomandibular joint

in patients with temporomandibular disorders

Joel B. Epstein, DMD, MSD, FRCDC,a John Caldwell, DDS,b and Gordon Black, DDS,c
Vancouver, British Columbia, Canada
VANCOUVER HOSPITAL AND HEALTH SCIENCES CENTRE

Objective. The objective of this study was to evaluate the utility of panoramic imaging in assessment of patients with
temporomandibular disorders (TMDs).
Study design. Fifty-five consecutive patients referred for diagnosis and management of facial pain and jaw dysfunction were
included. A single examiner completed the history and clinical examination on all patients. All patients received panoramic
imaging. On the basis of clinical and radiographic findings, a subset of patients received advanced imaging modalities. The
panoramic radiographs were interpreted by 2 examiners; if any disagreement was noted, a third examiner interpreted the
radiographs.
Results. Seventy-five percent of the patients had complaints of facial pain, and 75% exhibited tenderness in masticatory
muscles. Tenderness was present in TM joint regions in 62%. Altered bony anatomy was seen in 43.6% of panoramic radio-
graphs. Panoramic imaging did not lead to changes in clinical diagnosis in any of the patients seen, although the findings on
the radiographs did lead to requests for additional imaging studies in 3 cases, one of which was later referred for surgical inter-
vention because of radiographic findings.
Conclusion. Clinical findings may be of greater relevance leading to the diagnoses associated with TMD and to determination
of the need for additional imaging rather than the use of panoramic imaging in all patients with facial pain and TMD.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:236-9)

Temporomandibular disorder (TMD) is a collective
term that embraces a number of clinical conditions that
involve the temporomandibular joints (TMJs) and/or
masticatory muscles and associated structures.1 The
various clinical conditions are often characterized by
pain in the preauricular area, tenderness in the TMJ or
muscles of mastication, joint sounds, and limited func-
tion of the jaw.1-4 TMD is recognized as the most
common nontooth-related orofacial pain condition.
The responsibilities of the dental profession in the
management of head and neck pain require the confir-
mation or exclusion of TMJ dysfunction as the cause of
that pain.3
It has been demonstrated that clinical examination
alone cannot reliably lead to a correct diagnosis in
many cases of TMD.5 For that reason the highest stan-
dard of patient care suggests that it is appropriate to use
aDepartment of Dentistry, Vancouver Hospital and Health Sciences
Centre; Clinical Professor, University of British Columbia;
Medical/Dental Staff at the British Columbia Cancer Agency,
Vancouver, British Columbia, Canada; Professor, School of
Dentistry, University of Washington, Seattle.
bIn private practice, White Rock, British Columbia, Canada.
cIn private practice, Kelowna, British Columbia, Canada.
Received for publication Mar 9, 2000; returned for revision Jul 3,
2000; accepted for publication Nov 14, 2000.
Copyright 2001 by Mosby, Inc.
1079-2104/2001/$35.00 + 0 7/16/114158
doi:10.1067/moe.2001.114158
both patient history and clinical examination, supple-
mented with adjunctive diagnostic procedures as
needed, to develop a differential diagnosis.4
An assessment of the reliability, validity, risk, cost,
and usefulness of such adjunctive diagnostic proce-
dures is an essential part of the diagnostic process.
Radiographs are diagnostic tools that frequently may
be ordered when patients complain of pain or report
symptoms of TMD. Imaging of the TMJ may reveal
osseous or positional abnormalities, but even when
abnormalities are seen, it is not clear how frequently
these radiographs influence a clinicians decision
making and how they impact on patient care.6
A diagnostic test, including diagnostic imaging, is
considered to assist in patient care if it provides the
clinician with new information that alters the diagnosis
or the treatment plan.7 A radiograph that adds no new
information or that reveals only unsuspected benign
findings that do not contribute to the patient diagnosis
or care may result in unnecessary cost and exposure to
ionizing radiation. However, diagnostic testing may be
used to rule out diagnosis or treatment possibilities that
are being considered, and there are potential
medicolegal implications if a test that may impact the
diagnosis and treatment is not ordered.
Panoramic radiography has been advocated by some
clinicians as an appropriate imaging modality when
evaluating the TMJ, because it displays the TMJ area
and provides additional information about teeth and

236
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Epstein, Caldwell, and Black 237
Volume 92, Number 2

Table I. Patient-reported TM symptoms at presenta- Table II. Potential risk factors for TMD*
tion* No. %
No. % Jaw habit (bruxism, clenching) 29 53
Pain 41 75 Motor vehicle accident associated trauma 22 40
Headache 24 44 Other direct facial trauma 16 29
Earache 6 11 Nonidentified/unknown (idiopathic) 6 11
TMJ clicking 24 44 *Patients may have multiple risk factors.
Limited range of jaw movement 6 11 Including direct facial impact and flexion/extension movement.
Other 8 15
*Patients may have multiple symptoms.
Table III. TMD-related clinical findings*
No. %
other regions of the jaw.8
However, the diagnostic Clicking 39 71
utility of panoramic radiographs to assess patients with Crepitus 12 22
TMD remains unclear.8-10 It has been suggested that Locking 6 11
Muscle tenderness (masticatory) 41 75
panoramic imaging in combination with transcranial
Muscle tenderness (cervical) 12 22
and transorbital plain films or tomography provides TMJ tenderness 34 62
a comprehensive examination of bony anatomy.11 2 or more 43 78
Despite the lack of definitive information on the role of *Patients may have multiple symptoms.
imaging in groups of consecutive patients with TMD
and evaluation of its impact on patient care, recom-
mendations for imaging of the TMJ have been devel-
oped by a number of groups and individuals.8-14 obtained by using a Siemens OP1OA orthopantomo-
The purpose of this study was to evaluate a group gram (Majurinkatu, Finland) with an intensifying screen
of consecutive patients referred for diagnosis and containing Agfa film (Kontich, Belgium). MRI imaging
management of TMD to assess the value of panoramic was performed on a 1.5-tesla Signa unit (General
imaging as part of a baseline evaluation. This value Electric, Milwaukee, Wis) and interpreted on a plasma
would be measured by determining the number of operators screen. CT scans were obtained by using a
patients for whom additional information was provided General Electric CIT machine with Sterling laser film
by panoramic imaging that led to changes in diagnosis (Newark, NJ).
and patient management.
RESULTS
METHODS Individual patients presented with multiple symp-
The study sample consisted of 55 consecutive patients toms, clinical findings, and a combination of TMD
referred to a speciality practice for diagnosis and diagnoses. The most common complaints reported
management of facial pain and jaw dysfunction, 10 male were facial pain (75%), headache (44%), and TMJ
and 45 female, mean age 38.2 years (range, 7.4 to clicking (44%) (Table I). The most frequent potential
69.9 years). One investigator performed the clinical cause(s) for symptom onset, shown in Table II,
history and examination. Panoramic radiographs were included jaw habits (53%) and trauma from motor
completed for all patients, as was commonly done in that vehicle accidents (40%). The clinical findings,
practice at the time, and were interpreted in conjunction including joint sounds and joint and muscle tenderness,
with the clinical findings at the initial visit. A second are shown in Table III. Tenderness in the masticatory
interpretation of the panoramic radiographs was muscles was identified in 75% of patients, in the
conducted at the time of data collection for this study by cervical muscles in 22%, and in the TMJ in 62%. The
a second observer and interpreted without knowledge of mean maximum vertical opening of the jaw as
the clinical or previous radiographic findings. The measured between incisal edges was 38.5 mm (range,
results of these 2 interpretations were then compared. 15.0 to 56.0 mm). The clinical diagnoses, shown in
If there was a disagreement, the radiographs were Table IV, included myalgia (64%), arthralgia (49%),
reviewed by an additional examiner, and the majority disk displacement (51%), and osteoarthritis (5%).
opinion of the 3 examiners was used. In a subset of Deviation from normal osseous anatomy was seen in
patients advanced imaging (computed tomography [CT] 43.6% of panoramic films.
and/or magnetic resonance imaging [MRI]) was Additional imaging was requested in a total of 23
conducted, and the findings were compared to the find- patients and was completed for 20 (16 MRIs, 3 CTs, 3
ings from the panoramic films. Panoramic images were TMJ tomograms; 2 patients had both an MRI and CT).
238 Epstein, Caldwell, and Black
Table IV. TM-related clinical diagnosis(es)*
No.
Myalgia 35
Arthralgia 27
Disk displacement 28
Degenerative disease 3 5
Miscellaneous 3 5
*Patients may have multiple clinical diagnoses.
Table V. Diagnosis after advanced imaging
Total images Disk displacement Bony variations
MRI 16 11
CT 3 0
Tomogram 3 0
For 20 requests the advanced imaging was based on
clinical findings, and the remaining 3 requests were
based on panoramic findings. In 1 of the latter 3 requests,
a further referral for surgical assessment was made.
Disk displacement was seen in 11 of 16 MRIs (69%),
0 of 3 CTs, and 0 of 3 tomograms; bony change was
identified in 6 of 16 MRIs (38%), 2 of 3 CTs (67%),
and 2 of 3 tomograms (67%) (Table V). In 2 cases both
MRI and CT were performed. In 1 case both images
showed bony changes; in the other case, however, the
CT scan showed no abnormality, but the MRI scan
showed both bone and disk change. In all but 1 case,
the additional imaging confirmed the prior clinical
diagnoses.
Panoramic imaging did not lead to a change in the
clinical diagnosis in any patient. However, a change in
the treatment of 1 patient was seen, for whom addi-
tional CT imaging was ordered leading to a recom-
mendation for surgical treatment.
DISCUSSION
Recommendations for imaging of the TMJ have been
developed by the American Academy of Oral and
Maxillofacial Radiology and others.8-14 All indicate
that the decision to order diagnostic imaging should be
made after considering the history and clinical find-
ings, clinical diagnosis, cost of the examination,
amount of radiation exposure, the results of prior
examinations, as well as the tentative treatment plan
and expected outcome. The goal of imaging of the TMJ
is the same as imaging any other region of the body,
namely to evaluate the integrity of the structures when
disease is suspected, to confirm the extent of known
disease, to stage the progression of known disease, or
to evaluate the effects of treatment.11,13 A variety of
diseases affect the TMJ, including congenital and
developmental malformation of the mandible; acquired
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
August 2001
disorders including neoplasia, fracture, dislocation,
% ankylosis, and disk displacement; inflammatory
diseases that produce synovitis and capsulitis; a wide
64
49 range of arthritides; and various posttreatment condi-
51 tions. Diagnosis of some of these conditions cannot be
made by clinical examination alone.8
Panoramic radiography has frequently been used as a
simple, low-cost method to evaluate the bony structures
of the TMJ. In this technique the lateral slope and central
portions of the TMJ are visualized because of the
oblique orientation of the beam with respect to the long
axis of the condyle,14 but the depiction of the articular
6 eminence and fossa is not adequate for diagnosis of
2 other than advanced changes of shape and structure
2 because of the nature of the imaging and superimposi-
tion by the base of the skull and zygomatic arch.
Findings are usually limited to fractures, obvious
erosions, sclerosis, and osteophytes of the condyle.
Although the findings from this consecutive series of
55 patients with facial pain confirm that the panoramic
radiograph can show moderate to severe structural
abnormality of bone, it is also clear from this study that
the panoramic radiographs did not provide information
that influenced the diagnosis or patient management in
the majority of the cases of patients with TMD. Thus,
the clinical diagnoses, including those related to joint
structures, were not altered by the results of panoramic
imaging.
The use of diagnostic tests should be based on a
change in the diagnosis and/or management of patients
if a positive or negative finding is found on testing.7 If no
changes will be made regardless of the results of a test,
use of the test should not be considered. Effective use of
diagnostic tests requires that a clinician assign a pretest
probability of disease that reflects the clinicians confi-
dence that a condition does or does not exist. The utility
of a diagnostic test is to revise pretest likelihood or posi-
tive predictive value of a condition or, in ruling out a
condition, the negative predictive value or post-test like-
lihood of a negative test.7 Revision of diagnoses was not
seen by using panoramic films in the patients in this
study. In 3 cases of 55 patients additional imaging was
requested on the basis of panoramic imaging and
surgical treatment was recommended in 1 case.
Although our study did not address the use of
panoramic imaging for screening purposes in the general
population, the low prevalence of TMD suggests that
such diagnostic testing should not be considered for
screening. Even in a high risk population referred for the
diagnosis and management of facial pain and jaw
dysfunction, panoramic imaging had little impact on the
diagnosis, further investigation, or treatment. Because
clinical findings are predictive of internal derangement
and bone change, the utility of advanced imaging is also
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 92, Number 2
uncertain but may be important before consideration of
surgical intervention if nonsurgical management is not
effective. Other than ruling out significant structural
change in bone, such as fracture and developmental
abnormality, the use of panoramic radiography may not
add to the diagnosis or clinical management of patients.
In such cases it is likely that clinical findings will indi-
cate the diagnosis or need for detailed imaging of the
structure of the joint.
This study assessed the utility of panoramic imaging
in a series of patients with facial pain and TMD and did
not demonstrate the need for use in all patients with such
symptoms. Rather, it is recommended that imaging be
performed when clinical findings are directly related to
the TMJ, particularly in individuals with significant joint
findings or lack of response to therapy. As a result of this
study, our institution no longer routinely uses panoramic
radiographs for all patients with orofacial pain.
REFERENCES
1. List T, Dworkin SG, Harrison R, Huggins K. Research diag-
nostic criteria/TMJ disorders: comparing US and Sweden
clinics. J Dent Res 1996;75(spec issue):352.
2. Hansen LC, Hansen T, Peterson A. A comparison between clin-
ical findings and radiological findings in 259 TM joint patients.
J Prosthet Dent 1983;50:89-94.
3. McNeil C, Mohl ND, Rugh JD, Tanaka TT. Temporomandibular
disorders: diagnosis, management, education and research. J Am
Dent Assoc 1990;120:253-63.
Epstein, Caldwell, and Black 239
4. National Institute of Health Technology Assessment Conference
statement: management of TM disorders. Bethesda, Md, April
29-May 1, 1996.
5. Paesani D, Westersson PL, Hatala MP, Tallents RH, Brooks SL.
Accuracy of clinical diagnosis of TMJ internal derangements
and arthrosis. Oral Surg Oral Med Oral Pathol 1992;73:360-3.
6. Muir CB, Goss AN. The radiologic morphology of painful TM
joints. Oral Surg Oral Med Oral Pathol 1990;70:355-9.
7. Sheps SB, Schechter MT. The assessment of diagnostic tests.
JAMA 1984;252:2418-22.
8. Brooks SL, Brand JW, Gibbs SJ, Hollender L, Lurie AG, Omnell
KA, et al. Imaging of the temporomandibular joint: a position
paper of the American Academy of Oral and Maxillofacial
Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1997;83:609-18.
9. McNeil C, editor. Temporomandibular disorders: guidelines for
evaluation, diagnosis, and management. 2nd ed. Chicago:
Quintessence, 1993. p. 66-7.
10. Dixon DC. Diagnostic imaging of the temporomandibular joint.
Dent Clin North Am 1991;35:63-78.
11. Pharoah MJ. The prescription of diagnostic images for temporo-
mandibular joint disorders. J Orofac Pain 1999;13:251-4.
12. Hatcher DC. Craniofacial Imaging. Radiology 1996;19:27-34.
13. Larheim TA. Current trends in TMJ imaging. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 1995;80:555-76.
14. Hollender L. Imaging of the TMJ: the value of conventional
radiography and standard views and tomograms. In:
Worthington R, Evans JR, eds. Controversies in oral & maxillo-
facial surgery. Philadelphia: WB Saunders; 1994. p. 25-40.
Reprint requests:
J. B. Epstein, DMD, MSD, FRCDC
Department of Dentistry
Vancouver Hospital & Health Sciences Centre
855 W 12th Ave
Vancouver, BC, Canada V5Z 1M9