Detection of DegenerativeDiseaseof the TemporomandibularJoint by :ConciseCommunication

Harold A. Goldstein and Craig V. Bloom'

Philadelphia VeteransAdministration Medical Center and University of Pennsylvania,Philadelphia, Pennsylvania

Ninepatientswithfacialpainwereevaluatedwithlimitedbonescans.Thescm tigramscorrelatedwith microscopyin all patients(eight positive,one negative), although radiographs correlated wfth microscopy in only five patients (four posi tive, one negative). The degenerativediseaseprocessin the temporomandibular jointwas moreextensiveinthe patientswfthradiographicandscintigraphicabnor malities than in those with scintlgraphlcabnormalftiesalone. The limited bone scanappearsusefulindetectingearly degenerativechangesinthe temporomandi bular joint. J NuciMed21: 928—930,1980

Bone scintigraphy is a useful diagnostic modality for facial examination, and evaluation of occlusion and locating disease, both benign and malignant (1-11). The myofascial balance. Periapical dental radiographs, a application of this technique to oral disease has been facial series, TMJ radiographs, panograph, and tomo limited (12—27).Disorders of the temporomandibular grams were obtained on each patient. The nine patients joint (TMJ) have rarely been evaluated (12, 13). Laurie had surgery for their pain, at which time biopsy material (/4) suggests that this is a fertile area for investiga was obtained. tion. In addition to routine evaluation, each patient had a Facial pain has been, and still is, one of the most per limited bone scan after intravenous injection of 20 mCi plexing and challenging problems facing medicine and Tc-99m MDP. Two to 4 hr after injection, 500,000-count dentistry. The symptoms of TMJ disease are multiple. scintiphotos were obtained of the head in the anterior, The differential diagnosis of other entities that might be right lateral, and left lateral projections. considered is, then, a differential diagnosis of many, if RESULTS not all, pain-producing entities of the head and neck. Table I lists the various causes that should be considered The patients were classified into three groups on the in the differential diagnosis of TMJ pain. basis of radiographic, scintigraphic and histologic The limited bone scan is used in this study to evaluate findings. its sensitivity in locating the presence of organic dis Class 1. One patient had normal histology, bone ease. scintigrams, and radiographs. Histology of the glenoid fossa and mandibular condyle was normal. The meniscus MATERIALS AND METHODS was perforated. Nine patients with facial pain were evaluated. All had Example 1. (Fig. 1). This patient was a 26-year-old a detailed clinical history, a thorough oral and maxillo man who presented with 6 mo of intermittent, diffuse, dull, right TMJ pain. The dental radiographs, pano graph, facial and TMJ radiographs, and tomograms * Present address: Chief, Oral and Maxillofacial Surgery, Long Beach Veterans Administration Medical Center, Long Beach, CA. were within normal limits. The limited bone scan was Received Oct. 16, 1979; revision accepted June 5, 1980. also normal. A high condylectomy and meniscectomy For reprints contact: Harold A. Goldstein, MD, Dept. of , was performed, with resection of the auriculotemporal Hospital ofthe Univ. of Pennsylvania, Philadelphia, PA 19104. nerve, artery, and vein, and ligation of the superficial

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TABLE 1. DIFFERENTIALDIAGNOSISOF TMJ PAIN

I. Malocclusion II. Mandibularpain dysfunction syndrome III. Bruxism IV. Chronic subluxationor dislocation V. Osteoarthritis (degenerativearthritis) VI. Rheumatoidarthritis VII. Infectious arthritis VIII. Acute gouty arthritis IX. Acute traumatic arthritis x. Condylar fracture FIG.2. Example2:limitedbonescanandtomogramofrightTMJ XI. Tumors (most commonly osteoma) in 24-yew-old man with 18 mo of pain. XII. Ankylosis XIII. Whiplash (2°cervical traction) XIV. Myositis including the example, had normal condylar his XV. Condylar hyperplasia tology. XVI. Condylaragenesis Class 3. Four patients had abnormal radiographic, XVII. Psychogenicpain scintigraphic, and histologic findings. These patients had pain that had lasted from 3 to 8.5 yr. The surgical biopsy showed degenerative changes in the glenoid fossa and mandibular condyle. temporal artery and vein. The patient had been free of Example 3. (Fig. 3). The patient was a 33-year-old pain for 1 yr since surgery. man complaining of 8.5 yr of increasing pain and crep Class 2. Four patients had abnormal bone scintigrams itus of the right TMJ, with pain referring to the right ear. and abnormal histology, but normal radiographs. All had It had worsened progressively during the past 2 yr while pathologic findings in the glenoid fossa, with three of the he had been on trifluoperazine (Stelazine). His dental four having normal bone in the mandibular condyle. radiographs, panograph, and facial film series were all Example 2. (Fig. 2). This patient was a 24-year-old within normal limits. The TMJ radiographs showed a man who presented with 18 mo of right TMJ pain. The decreased joint space on the right. Tomograms of the dental radiographs, panograph, facial radiographs, TMJ right TMJ showed an intracapsular fragment of ossifi radiographs and tomograms were normal. The bone scan cation, erosion of the right articular eminence, and de showed increased activity in the right TMJ. A high creased right joint space. The scintigram showed marked condylectomy and meniscectomy with arthroplasty re increase of the tracer in the right TMJ and diffuse in lieved the pain. The surgical biopsy of the glenoid fossa crease in the mandible and maxilla. A high condylec showed periosteal necrosis and osteosclerosis. Biopsy of tomy and meniscectomy with arthroplasty was per the condyle of one of the four patients in this classifica formed, with complete relief of pain. Histology of all tion was abnormal, the microscopy being consistent with glenoid fossae demonstrated osteosclerosis, and all the diagnosis of degenerative disease with fibrosis of the condyles showed fibrosis of their marrow spaces. marrow spaces of the condyle. The other three patients, DISCUSSION A covert cause of diffuse facial pain is a diagnostic

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FIG.1. Example1:limitedbonescanandtomogramofrightTMJ FIG.3. Example3: limitedbonescanandtomogramofrightTMJ in 26-yew-old man with 6 mc of pain. in 33-year-old man with 8.5 yr of pain.

Volume 21, Number 10 929 GOLDSTEINAND BLOOM challenge. The nine patients studied have been classified 8. HOFFER PB, GENANT HK: joint imaging. by their radiographic,scintigraphic,and histologic SeminNuclMed6:121-l37,1976 9. GOLDSTEIN HA, TREvEs S: Bone scintigraphy of osteoid findings. Class I is for the patient with normal radio osteoma: A clinical review. C/in Nuci Med 3:359—363, graphs, bone scintigrams, and histology. Class 2 patients I978 are those with normal radiographic studies but abnormal 10. GILDAY DL, ASH JM, REILLY BJ: Radionuclide skeletal scintigraphy and histology. Class 3 patients are those survey for pediatric neoplasmas. Radiology 123:399—406, with abnormal radiographic, scintigraphic, and histo I977 II. SILBERSTEINEB, SAENGEREL, TOFE AJ, Ctal: Imaging logic results. The patient in Example 3 also had diffuse of bone metastases with @mTc@Sn@EHDP(diphosphonate), increase in the mandible and maxilla, secondary to ad ‘8F,and skeletal . A comparison of sensitivity. vanced periodontitis of his maxillary and mandibular Radiology107:551—555,1973 alveolar processes. 12. ALEXANDER JM, ALAVI A, HANSELL JR: Bone imaging The causes of facial pain, as listed in Table 1, are in evaluation of jaw lesions. J NucI Med 16:51 1, 1975 (abst) many; it may be caused by a mechanical, infectious, /3. GOLDSTEINHA, BLOOM CY, HANSELL JR: Diagnosis of congenital, or neoplastic process. A well-defined, temporomandibularjoint disease. J NucI Med 20:603, 1979 nonorganic cause is pain of a psychogenic origin. The (abst) diagnosis of temporomandibular joint disease is difficult /4. LAURIE AG: Applications of nuclear medicine in dentistry. when based on clinical evaluation and routine radio CRC Handbook: Series in Clinical Laboratory Science. Section A: Nuclear Medicine, Spencer RP, ed, Cleveland, graphic techniques. In fact, in four of eight patients with CRC Press, 1977 proven bone disease, the radiographs were normal. 15. Tow DE, GARCIA DA, JANSONS D, et al: Bone scan in However, in all eight of these patients the bone scinti dental diseases. I Nucl Med I9:845—847,1978 gram picked up evidence of an abnormality. In the one /6. GARCIA DA, Tow DE, KAPUR KK, et al: Relativeaccretion Class I patient, with a perforated meniscus and no os of 99mTc@polyphosphateby forming and resorbing bone sys tems in rats: Its significance in the pathologic basis of bone seous disease, the bone scintigram, as expected, remained scanning.JNuclMed17:93-97,1976 normal. 17. LURIE AG, MATTESON SR: @mTc.diphosphonate bone Therefore, in patients with facial pain and normal imaging and uptake in healing rat extraction sockets. J Nucl radiograms, the limited bone scan appears to be useful Med 17:688-692,1976 in detecting early degenerative TMJ changes. 18. 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