RADIOLOGY/IMAGING
Conventional and functional imaging in the evaluation
of temporomandibular joint rheumatoid arthritis:
a systematic review
Mel Mupparapu, DMD/Sophia Oak, BA/Yu-Cheng Chang, DDS/Abass Alavi, MD
Objectives: To evaluate the efficacy of diagnostic imaging for
temporomandibular joint rheumatoid arthritis (TMJ RA). In-
flammation of the TMJ has a high correlation (> 17%) with the
late stages of RA. Clinical recognition of TMJ RA using diagnos-
tic imaging techniques such as computed tomography (CT),
magnetic resonance imaging (MRI), and cone beam computed
tomography (CBCT), is limited to osseous and soft tissue com-
ponents of the TMJ. Positron emission tomography (PET) and
positron emission tomography/CT (PET/CT) are novel technol-
ogies that have shown increasing relevance in the detection
and management of TMJ RA. Method and materials: Follow-
ing the preferred reporting items for systematic reviews and
meta-analysis (PRISMA, 2009) guidelines, and using databases
such as PubMed, Ovid Medline, Google Scholar, Web of Science,
Scopus, and EBSCOhost, 94 publications were identified, and 27
Key words: computed tomography, conventional imaging, functional imaging, panoramic, positron emission tomography,
radiography, rheumatoid arthritis, temporomandibular joint, x-ray tomography
Rheumatoid arthritis (RA) is a systemic autoimmune disease
characterized by joint pain, inflammation, fatigue, and acceler-
ated loss of muscle mass.1 It is a common inflammatory arthritis
that accounts for 9 million physician visits in the US annually.2
It is known that patients with RA have a higher risk for develop-
ing periodontal disease3 and hence should be carefully moni-
tored. There are four stages of RA. Stage I (mild) is characterized
by synovitis, an inflammation of the synovial membrane. Stage
II (moderate) is characterized by the spread of inflammation in
the synovial tissue, which affects the joint cavity space across
joint cartilage. This will gradually result in the destruction of the
cartilage, accompanied by a narrowing of the joint. Stage III
(severe) is marked by formation of pannus in the synovium.
742 QUINTESSENCE INTERNATIONAL | volume 50 • number 9 • October 2019
studies were selected for this systematic review. A flowchart of
the comprehensive study selection was generated. Quality as-
sessment and data extraction were performed independently
by three reviewers. Results: It was noted that two-dimensional
radiographs, CBCT, multidetector CT, and MRI are the most
commonly used methods in TMJ RA assessment, although they
are not useful for determination of active disease. MRI has ex-
cellent contrast resolution and can acquire dynamic imaging
for demonstration of the functionality of the TMJ. CT and ultra-
sound imaging also have specific indication in imaging the TMJ.
PET used in conjunction with CT is the only imaging modality
that can quantify TMJ RA in active disease. Conclusions:
PET/CT images provide unique quantitative information that
cannot be obtained from any other imaging modalities.
(Quintessence Int 2019;50:742–753; doi: 10.3290/j.qi.a43046)
Pannus is an abnormal layer of fibrovascular tissue or granula-
tion tissue that thickens the synovium. Pannus causes loss of
joint cartilage and can ultimately result in exposed bone
beneath the cartilage. These erosions and joint deformities can
be monitored by various imaging techniques. Lastly, stage IV
(terminal) RA includes the formation of fibrous tissue and/or
the fusing of bone, which results in ceased joint function.4
The determination of whether or not a definitive diagnosis
of RA can be made is based on the 2010 American College of
Rheumatology (ACR)/European League Against Rheumatism
(ELAR) guidelines.5 Typically, the target patient would be one
with at least joint swelling (synovitis) or synovitis in any joint
that cannot be explained by another disease. It is reasonable to
 Mupparapu et al

Table 1 Joint ACR/ELAR summary of guidelines5 and diagnostic criteria for rheumatoid arthritis*

Joint involvement Serology Acute phase reactants Duration of symptoms

1 large joint (0) Negative RF, negative ACPA (0) CRP, ESR normal (0) < 6 wk (0)
2–10 large joints (1) Low + RF, low + ACPA (2) Abnormal CRP or abnormal ESR (1) > 6 wk (1)
1–3 small joints (2) High + RF, high + ACPA (3)
4–10 small joints (3)
> 10 joints (with at least 1 small joint) (5)
*Total score in parentheses: 6 or above out of 10 indicates a definitive diagnosis of RA.
ACR, American College of Rheumatology; ACPA, anti-citrullinated protein antibody; CRP, C-reactive protein; ELAR, European League Against Rheumatism; ESR, erythrocyte sedimentation rate; RF,
rheumatoid factor.

think that the temporomandibular joint (TMJ) falls under the
small joint category for the applicability of the ACR/ELAR
guidelines. The summary of guidelines can be seen in Table 1.
Inflammation of the TMJ has high correlation (> 17%) with
the late stages of RA.6,7 Based on the ACR/ELAR criteria for the
diagnosis of RA,8 TMJ RA diagnosis in the absence of any other
joint involvement in the body can only be made if it is bilateral
and the following criteria are met:
■ low or high positive rheumatoid factor (RF) and anti-citrul-
linated protein antibody (ACPA)
■ abnormal C-reactive protein (CRP) and erythrocyte sedi-
mentation rate (ESR)
■ duration of symptoms should be over 6 weeks.
The radiographic diagnosis plays a vital role in the assessment
of TMJ RA. However, it is notable that the TMJ is involved in
approximately 50% of cases with rheumatoid diseases such as
RA, ankylosing spondylitis, and psoriatic arthritis.9
Imaging the TMJ allows clinicians to evaluate the integrity
and relationships of the osseous components and soft tissue.

Ovid Medline
PubMed, Google Scholar, Web of Science, Scopus, EBSCOhost,
(1950–Sept 2018),
until Sept 2018; until Sept 2018; until Sept 2018; until Sept 2018; until Sept 2018;
until Sept 2018;
550 citations 8,016 citations 294 citations 230 citations 822 citations
422 citations

8,251 non-duplicate
citations screened

Inclusion/
8,157 articles excluded
exclusion criteria
after title/abstract screen
applied

94 articles reviewed

Inclusion/
65 articles excluded 2 articles excluded
exclusion criteria
after full text screen during data extraction
applied

27 articles included
1

Fig 1 The PRISMA flowchart summarizes the search strategies for each electronic database and the final studies that are included.

QUINTESSENCE INTERNATIONAL | volume 50 • number 9 • October 2019 743

 RADIOLOGY/IMAGING

Table 2 Characteristics of imaging modality, including advantages, disadvantages, and common clinical applications

Characteristics Plain images Panoramic radiograph CBCT/CT MDCT

Main 2D images obtained through 2D tomogram of the maxilla 3D images obtained through A fast type of CT
characteristics the use of x-rays and mandible the use of x-ray beams from
various angles
Resolution High High High for bone tissue, low for soft High
tissue
Sensitivity Fair Good Excellent Excellent
Specificity High High High Moderate
Radiation dose Low Low High High
Contrast Low Low High High
Application Anatomical Anatomical Anatomical Anatomical
Cost Low Low Intermediate Intermediate
Diagnostic Moderate Low High for osseous changes High
accuracy
Advantages Faster technique, low cost Panoramic features, low cost, Quick technique, brightness and Up to eight times greater than
low radiation dose contrast can be manipulated on the conventional single-slice CT,
the viewing screen, excellent reconstruction in different slice
resolution widths, excellent resolution,
better multi-planar reconstruc-
tion and 3D display
Disadvantages Poor magnification, radiation Poor magnification, technique Radiation exposure, poor soft Radiation exposure, large
exposure, distortions with specific, does not depict subtle tissue contrast, tissue volume of data, side effects of IV
superimposed structures and osseous change or soft tissues, nonspecificity contrast
inconsistent head position, does image distortion
not detect subtle osseous
changes or soft tissues, 2D
technique
Common clinical Assessment of common dental Assessment of advanced Assessment of TMD; evaluation Diagnosis and management of
applications pathologies such as cavities or periodontal disease, oral cysts, of dental implant placement; craniofacial injuries and
(dental) abscesses impacted teeth, TMD, sinusitis, evaluation of jaw, sinuses, nerve pathology; assessment of cysts,
tumors, and oral cancer canals, and nasal cavity; benign and malignant tumors
detection and measurement of of the head and neck
jaw tumors; examination of
bone structure and tooth
orientation
CBCT, cone beam computed tomography; CT, computed tomography; IV, intravenous; MDCT, multidetector computed tomography; MRI, magnetic resonance imaging; OSCCA, oral squamous cell
carcinoma; PET, positron emission tomography; TMD, temporomandibular disorders; TMJ, temporomandibular joint.

The choice of TMJ RA imaging is dependent on several factors,
such as radiation dose, cost, availability, diagnostic information
provided, and whether hard or soft tissue is imaged.10 When
diagnosing TMJ RA, hard tissues are the first to be evaluated.
Osseous contours, positional relationship of the condyle and gle-
noid fossa, and range of motion are assessed.11-13 Soft tissue
imaging offers information about disc position and morphology,
as well as abnormalities surrounding the muscle and soft tissue.12
Functional imaging modality (scintigraphy) has been used
in the past to evaluate TMJ RA but is not in routine use due to
the limitations like increased radiation dose, low specificity,
and poor resolution.13 The present systematic review was initi-
ated to assess the existing standards of diagnosis for TMJ RA.
Based on the review of patient data from the full-text articles,
comparisons were drawn for each imaging modality regarding
the general resolution, sensitivity, specificity, advantages, dis-
advantages, radiation dose used, image contrast, applications,
cost, common clinical applications. and limitations. The pre-
ferred reporting items for systematic reviews and meta-analysis
(PRISMA) item list for was used as a guide in this review.
Method and materials
Electronic searching (identification and screening)
For this study, search strategies were developed for each elec-
tronic database, summarized in Fig 1. The search strategies
used a combination of pertinent phrases and key words. Elec-

744 QUINTESSENCE INTERNATIONAL | volume 50 • number 9 • October 2019

 Mupparapu et al

MRI PET/CT Ultrasound Technetium bone scan

2D and 3D images that use magnetic Images obtained through the use of Ultrasound-based imaging A nuclear medicine procedure that
fields and radio frequency pulses radiotracers to monitor inflammation uses technetium 99m
and metabolism
High Low for PET Low High

Excellent Excellent Good High

Moderate High High Low
None Moderate None Low
High High High High
Metabolic, functional, molecular Anatomical, functional, molecular Anatomical Functional, anatomical
Intermediate High Low Low
High High Moderate High for osseous changes

No radiation exposure, better soft
tissue contrast than CT, highly
versatile: a variety of pulse sequences
can be used for visualizing specific
tissues and pathology, high spatial
resolution and soft tissue contrast
Longer examination time, high cost,
slice thickness cannot be altered once
reformatted, patient cannot have
metal components in body (eg,
pacemakers)
High sensitivity, achieves a more
extensive survey compared to other
modalities, quantitative analysis can
be achieved
Radiation exposure, motion artifact
problem, challenging interpretation,
most expensive technique
No radiation exposure, does not High sensitivity, high spatial
usually require injection of a contrast resolution
medium (dye), visualization of hard
and soft tissue, easy technique, low
cost
Quality and interpretation varied by Lack of specificity, high false-negative
skill, multiple factors can affect image rate
quality (ie, presence of air and
calcified areas in the body)

Diagnosis and management of TMJ
pathology; diagnosis and manage-
ment of direct nerve trauma
(compression); diagnosis and
management of osteonecrosis of the
jaw
Assessment of OSCCA; response to
tumor treatment, diagnosing
recurrence, detecting residual
pathology and distant metastases;
localization of occult primary tumor
Examination of salivary glands
disorders, periapical lesions, lymph
nodes (benign/malignant),
intraosseous lesions, and TMD;
assessment of masticatory muscles in
TMD; examination of congenital
vascular lesions of head and neck and
primary lesions of the tongue
Diagnosing and differentiating body
infections from soft tissue infections,
eg dental osteomyelitis from cellulitis;
assessment of benign and metastatic
bone tumors of oral regions;
assessment of TMJs

tronic searches were conducted using the following databases:
PubMed, Ovid Medline (1950 to present), Google Scholar, Web
of Science, Scopus, and EBSCOhost.
The search strategies and controlled vocabularies used
were: rheumatoid arthritis, temporomandibular joint, conven-
tional imaging, functional imaging, cone beam computed
tomography (CBCT), magnetic resonance imaging (MRI), ultra-
sound, multiple detector computed tomography, plain images,
technetium bone scan, panoramic radiograph, and positron
emission tomography (PET). A flowchart was created following
the 2009 PRISMA flow diagram, and of the 94 publications con-
sidered, 27 studies were analyzed.
Data extraction (inclusion and exclusion criteria)
The inclusion criteria were created to evaluate each study based
on its publication characteristics, study design, study relevance,
and study conduct. Inclusion characteristics such as full-text
peer-reviewed publication and year of publication were consid-
ered during data extraction. To avoid publication bias, all arti-
cles spanned approximately two decades. Information from
each source was compiled while accounting for the weaknesses
and limitations of each article. Each article was assigned a level
(A to I) based on the strength of the evidence using the guide-
lines of the US Preventive Services Task Force.14 Studies that
were weak in subject number or contained evident biases were
considered but not contributive in the present summary.

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 RADIOLOGY/IMAGING
A board-certified nuclear medicine specialist, a board-certi-
fied oral and maxillofacial radiologist, a board-certified peri-
odontist, and a calibrated research student were involved in
the screening, inclusion, and review of all the articles. If there
was a disagreement, the issue was discussed and, if necessary,
an additional reviewer who was familiar with both TMJ RA and
imaging was consulted.
Results
Literature search
The electronic search of six databases until September 2018
produced a total of 10,334 citations, many of which were dupli-
cates. The results for each of the search strategies are summa-
rized in the flowchart (Fig 1). By eliminating duplicate articles
and inapplicable citations using the eligibility criteria, the total
number of full-text articles was 94. After excluding single-case
reports and review articles, 27 case series were included in the
systematic review. Based on the review of the 27 case series
and the authors’ conclusions, a comparison table was created
(Table 2) that summarized the main characteristics of each
imaging modality, resolutions, sensitivity, specificity, advan-
tages, disadvantages, radiation dose, image contrast, applica-
tions, cost, common clinical applications, and limitations.
Discussion
Although the specific objective was to identify the best imag-
ing modality for the diagnosis and follow-up of TMJ RA, indi-
vidual imaging modalities were also studied for their own
merit. TMJ RA should be distinguished from TMJ osteoarthritis
(TMJ OA) and other forms of septic arthritis (TMJ SA), although
it would be challenging to do so based solely on the radio-
graphs.
746 QUINTESSENCE INTERNATIONAL | volume 50 • number 9 • October 2019
Fig 2 Panoramic radiograph showing
mandible and maxilla and the remaining
dentition. Note the condyles are bilaterally
slightly out of the fossa due to bite block
positioning. Also note the elongated styloids
and calcified carotid artery bilaterally.
Radiographic line pair resolution based on the published lit-
erature is used to compare the imaging modalities. Contrast res-
olution for images is categorized into low, moderate, and high
values, again based on the published literature for intraoral radio-
graphs, panoramic radiographs, CBCT, MDCT, MRI, ultrasound,
scintigraphy, and PET/CT. Based on the findings, individual
modalities and their roles in the diagnosis of TMJ RA are discussed
below. Studies were placed into various categories of net benefit
based on the US Preventive Services Task Force grades and its
recommendations.14 The following are the specific recommenda-
tions from the Agency for Healthcare Research and Quality14:
■ Grade A: There is high certainty that the net benefit is sub-
stantial
■ Grade B: There is moderate certainty that the net benefit is
substantial
■ Grade C: There is at least moderate certainty that the net
benefit is small
Fig 3 Patient
positioned in a
CS 9300 cone beam
computed tomo-
graphy x-ray machine
(Carestream Dental)
for a tomographic
procedure of
3 condyles.
 Mupparapu et al

Fig 4 Cone beam computed tomography

Right Left
(CBCT) temporomandibular joint views
(coronal and sagittal) reconstructed from the
axial slicing from the captured CBCT data.
Right and left condyles are indicated on the
coronal views.

■ Grade D: There is no net benefit or that the harms outweigh patients with RA, but it is difficult to diagnose in the TMJ, par-
the benefit ticularly using plain radiographs.18-20
■ Grade I: Evidence is lacking.

Role of plain images in the diagnosis of TMJ RA

5a 5b
Planar radiographic images (plain) are two-dimensional (2D)
views that are limited to imaging of the osseous components
of the TMJ RA patients since soft tissue planar images are not
considered to be of diagnostic quality. Film or digital planar
images are rarely definitive for TMJ RA as evaluation of the soft
tissues is necessary for diagnosis. However, plain images can
serve as a useful baseline for follow-up. Plain images have high
resolution, high specificity, and low cost.15 The limitations
include radiation exposure, magnification, distortions with
superimposed structures, and low sensitivity.16,17 5c 5d
The radiographic features of TMJ RA are not very distinct
and there are no pathognomonic radiographic signs of the dis-
ease other than the fact that the involvement of the joint leads
to erosion or loss of articulating surfaces, loss of joint space,
morphologic alterations to the glenoid fossa and the articular
eminence, and, on occasion, fibrous ankylosis. Although all of
these changes can be noted on a variety of plain radiographs,
there are no specific radiographic signs that can be attributed
Figs 5a to 5d Cone beam computed tomography coronal (a and b)
to TMJ RA other than loss of bony architecture. Osteoporosis and sagittal (c and d) multiplanar reconstructions of normal right
may be the first and only change that happens in the bone in (a and c) and left (b and d) temporomandibular joint.

QUINTESSENCE INTERNATIONAL | volume 50 • number 9 • October 2019 747

 RADIOLOGY/IMAGING

6 7 8

Fig 6 Lateral view cone beam computed
tomography 3D rendering of a patient with
bilateral temporomandibular joint rheuma-
toid arthritis. Note the anterior open bite due
to destruction and upward movement of the
condyles within the glenoid fossa. The pa-
tient is on concurrent orthodontic therapy.
Fig 7 Frontal view cone beam computed
tomography 3D rendering of a patient with
bilateral temporomandibular joint rheuma-
toid arthritis. Similar to the lateral view, an-
terior open bite is noted clearly in this view.
The patient is on concurrent orthodontic
therapy.
Fig 8 Sagittal T1-weighted magnetic reso-
nance image showing the left condyle in the
glenoid fossa in closed mouth position and
the disc in the normal position interposed
between the head of the condyle and the
posterior slope of the fossa (D). The bright
signal within the condyle is due to the bone
marrow. The cortical bone itself has no signal.

Role of panoramic radiography (PR) Role of CBCT in the diagnosis of TMJ RA

in the diagnosis of TMJ RA
Panoramic radiography (PR) is a hard tissue imaging technique
that gives an overview of the jaws and teeth. Although the osse-
ous components, such as the mandibular condyles and glenoid
fossa, can be imaged using PR, image distortion is common.21
Since the imaging of the condyles depends upon the precise
position of the patient within the machine (and hence within
the focal trough), distortions in both vertical and horizontal
dimensions occur frequently.21 The image quality varies and is
operator dependent. The true shape of the condyles is rarely
recognized on any panoramic images. The precise location of
the articulating surface and medial and lateral poles also cannot
be imaged without the use of markers. Therefore, PR has limited
value in TMJ RA assessment.22 However, some of the advantages
of PR include high resolution, high specificity, and low cost.23,24
PR can be used for preliminary evaluation of joint spaces,
the articular eminence, and the position of the condyles rela-
tive to the occlusion. Panoramic x-ray machines have built-in
radiographic programs for TMJ imaging, as a dose-reduction
mechanism for multiple viewing options. Some of the common
options include standard panoramic radiograph (Fig 2), lateral
TMJ (closed and open), and postero-anterior TMJ views (closed
and open).23
CBCT is an imaging technique that provides volumetric, surface,
and sectional information about TMJ RA in all three dimensions
(Figs 3 and 4). CBCT has high motion detectability, high sensitiv-
ity, high specificity, and low cost.25 However, CBCT is limited in its
ability to diagnose anything other than condylar pathologic
changes. The resolution is high for bone tissue and low for soft
tissue. Thus, the diagnostic information obtained by CBCT is lim-
ited to the morphology of the osseous joint components, cortical
bone integrity, and subcortical bone destruction or production.26
The disadvantages of CBCT include high radiation exposure,
poor soft tissue contrast, and tissue nonspecificity.27 Imaging of
the disc cannot be accomplished using CBCT or multidetector CT
(MDCT). This necessitates the use of MRI in such cases.28,29
Since the synovial membrane inflammation of all the joints
involved in RA, including the TMJ, is manifested by progressive
bony erosions and cartilage destruction, CBCT imaging helps in
the identification of these changes based on the severity of the
TMJ RA. The primary advantages of CBCT are the versatility of
patient positioning (either standing, supine, or sitting postures
based on the machine used), the ease of acquisition, and the
relative reduction in radiation doses compared to MDCT and
higher spatial resolution of the multiplanar reconstructions so
created from the acquired volumes (Figs 5 to 7).29

748 QUINTESSENCE INTERNATIONAL | volume 50 • number 9 • October 2019

 Mupparapu et al

9a 9b 9c

Figs 9a to 9c Positron emission tomography (PET) maximum intensity projections: The lit-up regions indicate temporomandibular joint (TMJ)
metabolic activity. (a) Axial, (b) coronal, and (c) sagittal sections. ROVER software was used to quantify TMJ rheumatoid arthritis.

10a 10b 10c

Figs 10a to 10c Fusion technique. Projections of NaF-positron emission tomography/computed tomography (PET/CT): The multiplanar
reconstructions, (a) axial, (b) coronal, and (c) sagittal, show how the spherical masks on ROVER adjust their size to correspond to the region of
interest (ROI).

Role of MRI in TMJ RA The MRI examination is extremely versatile; a variety of

MRI is a functional imaging modality characterized by its use
of magnetic fields and radio frequency pulses. MRI is help-
ful in discerning different TMJ pathologies.30 MRI has high res-
olution, excellent sensitivity, moderate specificity, and high
diagnostic accuracy.30 One of the advantages of MRI is that it
does not use radiation. Compared to CT, MRI has better soft
tissue contrast but fewer viewing options. The limitations of
MRI include long examination time, high cost, and metal sensi-
tivity.30 MRI can be a useful technique in evaluating TMJ RA. By
assessing the articular disc and its location relative to the con-
dyle in both closed- and open-mouth positions, MRI can visu-
alize the presence of a displaced disc, which is a critical sign for
TMJ RA (Fig 8).30 Larheim et al31 determined that gadolinium-
enhanced MRI of the TMJ effectively depicted the proliferating
synovium of rheumatic inflammatory joint disease of 36 TMJs
in 27 patients after injection of gadopentetate dimeglumine.31
pulse sequences can be used to visualize specific tissues and
pathology. Studies with MRI have shown potential for accurate
evaluation of the soft tissue components of the joint.31 Typically,
the T1-weighted (T1W) and T2-weighted (T2W) images are used
for evaluation of TMJ disc. In T1W images, cortical erosions can
be noted along with disc displacement and thinning of bone.
The pannus, the synovial granulomatous tissue (if noted), has an
intermediate signal density in both T1W and T2W images. In
T2W images, there might be increased signal intensity in the
joint space representing joint fluid. There can be increased sig-
nal intensity in condylar marrow space due to inflammatory
edema or decreased signal intensity due to sclerosis.31
Role of MDCT in TMJ RA
MDCT is an important adjunct to the clinical diagnosis of TMJ
RA and is particularly important for follow-up of these patients

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 RADIOLOGY/IMAGING
11
over time. CT of the TMJ helps in the identification of the extent
of damage to the joints and helps in surgical planning via 3D
reconstruction if the damage is extensive and needs surgical
intervention.32 Although synovial proliferation cannot be char-
acterized by MDCT alone, the erosive changes can be identified
accurately. MDCT is a fast acquisition CT. MDCT enables com-
prehensive evaluation of the osseous components of the TMJ
and is a valuable tool for surgical planning. Sagittal, coronal,
and three-dimensionally (3D) reformatted MDCT images can
depict osseous TMJ lesions, and their relationship to adjacent
structures.33 Overall, MDCT has high resolution, excellent spec-
ificity, and high diagnostic accuracy. Other advantages of
MDCT include high speed (up to eight times faster than the
conventional single-slice CT), and excellent multiplanar recon-
struction. Limitations include radiation exposure, low sensitiv-
ity, high cost, and large data volume.33
Role of ultrasound in TMJ RA
Ultrasound is an inexpensive, noninvasive diagnostic imaging
modality. It is widely available and highly specific. The sensitiv-
ity of ultrasound is relatively high for the evaluation of disc and
cartilage displacement, joint effusion, and condylar erosion.34
However, MRI diagnoses of TMJ RA are preferred over ultra-
sound diagnoses by clinicians due to higher specificity. Limita-
tions of ultrasound usage include image distortion and inter-
pretation variability.35
Ultrasound cannot be used for the evaluation of TMJ RA,
because it does not provide definitive diagnoses.35 Clinically, only
the osseous surfaces, not the whole cortex or spongiosa, can be
750 QUINTESSENCE INTERNATIONAL | volume 50 • number 9 • October 2019
Fig 11 Maximum intensity whole body positron emission
tomography projections of temporomandibular joint (TMJ)
metabolic activity in a patient with rheumatoid arthritis.
ROVER software was used to quantify TMJ rheumatoid arthritis.
visualized due to the nature of ultrasound frequencies. The chal-
lenge of visualizing the TMJ via ultrasound is also dependent on
the limited accessibility of the deep structures due to absorption
of the sound waves by the lateral portion of the head of the con-
dyle and the zygomatic process of the temporal bone.34-36
Role of technetium bone scanning in TMJ RA
Nuclear medicine scans are used to evaluate osseous patholo-
gies. Technetium-99m bone scans are among the most com-
monly used scintigraphy studies. Technetium bone scans have
high resolution and high sensitivity.37 Limitations include lack
of specificity, radiation exposure, and high false-negative rate.
Advantages include low cost and high diagnostic accuracy for
osseous pathologies. Bone scans may be valuable for assessing
the progress of TMJ inflammation or remodeling.37
Role of PET in the diagnosis of TMJ RA
PET plays an important role in the detection, characterization,
and monitoring of various metastatic diseases.38 Recent stud-
ies39-43 have suggested that metabolic activity in TMJ can be
detected with accuracy using PET/CT and PET/MRI. Unlike
other imaging modalities, PET scans can detect diseases before
anatomical changes occur. In small areas like the TMJ, PET can
be a valuable tool in visualizing subtle metabolic changes.
Other advantages of PET in TMJ RA include high sensitivity,
high specificity, and ability to quantify metabolic cell activity.
The limitations of PET include radiation exposure, motion arti-
fact problem, and high cost.
 Mupparapu et al

Currently, conventional radiography can only detect osse- Conclusions

ous and cartilaginous structural changes that occur in the late
stages of RA. A growing number of studies have employed PET
to overcome some of these deficiencies.41,42 Currently, PET is
the only imaging modality that offers accurate quantification
of cell activity and volumetric measurements. Typically, ana-
lysis of PET image datasets can be qualitatively and quantita-
tively performed by measuring the standardized uptake val-
ues (SUV) and the region volumes using the image analysis
software ROVER (ABX Advanced Biochemical Compounds).44
This allows for accurate assessment of TMJ RA, including valu-
able staging information. Software such as ROVER, OsiriX
(Pixmeo), and EBW (Philips) have become increasingly import-
ant in assessing PET scans.44 These semi-automated image
analysis software programs allow users to quantify metabol-
ically active volumes using PET scans superimposed with MRI
or CT scans (Figs 9 to 11).
In diagnosing TMJ RA, fluorodeoxyglucose (FDG) is one of
the most commonly used radiotracers.39 There have been
recent clinical studies citing the utility of FDG PET in diagnos-
ing the early stages of TMD.41 The degree of synovial inflamma-
tion can easily be detected by FDG-PET/CT. Inflammatory activ-
ity in small joints such as the TMJ has not been studied as
extensively as that in large joints.41 However, in the currently
available literature, FDG-PET/CT, especially compared to con-
ventional radiography, has shown high potential in staging,
planning, post-treatment assessment, forecasting prognosis,
and restaging TMJ RA.45
The correct selection criteria of an image modality should be
based on the individual characteristics of the patient. When
selecting the type of imaging technique, it is important to con-
sider the specific clinical problem, applicability of the technique,
type of tissue to be visualized, radiation exposure, sensitivity,
and cost of the examination. The usage of more specialized
imaging modalities such as PET is uncommon in diagnosing
TMJ RA in clinical settings. However, they offer greater accuracy
than conventional imaging techniques. Planar digital images,
CBCT, MDCT, and MRI are currently the most commonly used
methods in imaging TMJ RA.
MRI offers superior contrast resolution and dynamic imag-
ing of the joint. This allows for a detailed examination of the
anatomy as well as the biomechanics of the joint through open-
and closed-mouth imaging. For the bony elements of TMJ, CT is
a comparable alternative technique. CT allows for 3D recon-
structions. The relative advantages of CT over MRI include
higher resolution.
For optimal results, functional imaging techniques such as
PET can be superimposed with MRI or CT scans. The benefits of
PET, such as its exceptional accuracy, excellent sensitivity, and
specificity, make it a novel candidate for diagnosing TMJ RA.
With the use of imaging analysis software, PET/CT images can
provide unique quantitative information that cannot be
obtained from any other imaging modalities. Precise quantifi-
cation of cell activity and volumetric measurements can be
highly valuable in early diagnosis and treatment planning.

References
1. Oelzner P, Lehmann G. Hypercalcemia
in rheumatoid arthritis: relationship with
disease activity and bone metabolism.
Rheumatol Int 2006;26:908–915.
2. Kubota K, Ito K. Whole-body FDG-PET/
CT on rheumatoid arthritis of large joints.
Ann Nucl Med 2009;23:783–791.
3. Pons-Fuster A, Rodriguez Agudo C,
Galvez Munoz P, Saiz Cuenca E, Pina Perez
FM, Lopez- Jornet P. Clinical evaluation of
periodontal disease in patients with rheuma-
toid arthritis: a cross-sectional study.
Quintessence Int 2015;46:817–822.
4. Majithia V, Geraci S. Rheumatoid arthritis:
diagnosis and management. Am J Med 2007;
120:936–939.
5. Vonkeman HE, Van de laar MA. The new
European League Against Rheumatism/
American College of Rheumatology diagnos-
tic criteria for rheumatoid arthritis: how are
they performing? Curr Opin Rheumatol
2013;25:354–359.
6. Aletaha D, Neogi T, Silman A, Funovits J,
Felson DT. 2010 Rheumatoid arthritis classifi-
cation criteria. An American College of
Rheumatology/European League Against
Rheumatism collaborative initiative. Arthritis
Rheumatol 2010;62:2569–2581.
7. Herring SW. TMJ anatomy and animal
models. J Musculoskelet Neuronal Interact
2003;3:391–394.
8. Al-Saleh MA, Alsufyani N, Flores-Mir C,
Nebbe B, Major PW. Changes in temporo-
mandibular joint morphology in class II
patients treated with fixed mandibular re-
positioning and evaluated through 3D imag-
ing: a systematic review. Orthod Craniofac
Res 2015;18:185–201.
9. Tamimi D, Jalali E, Hatcher D. Temporo-
mandibular joint imaging. Radiol Clin North
Am 2018;56:157–175.
10. Helenius LM, Hallikainen D, Helenius I,
Meurman JH, Könönen M, Leirisalo-Repo M.
Clinical and radiographic findings of the
temporomandibular joint in patients with
various rheumatic diseases. A case-control
study. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2005;99:455–463.

QUINTESSENCE INTERNATIONAL | volume 50 • number 9 • October 2019 751

 RADIOLOGY/IMAGING
11. Tomas X, Pomes J, Berenguer J, et al.
MR imaging of temporomandibular joint
dysfunction. Radiographics 2006;26:765–781.
12. Pihut M, Szuta M, Ferendiuk E,
Zeńczak-Więckiewicz D. Differential diagnos-
tics of pain in the course of trigeminal neu-
ralgia and temporomandibular joint dys-
function. Biomed Res Int 2014;2014:563786.
13. Mupparapu M, Nadeau C. Oral and
maxillofacial imaging. Dent Clin North Am
2016;60:1–37.
14. Agency for Healthcare Research and
Quality. Guide to clinical preventive services,
2014. Appendix A. How the U.S. Preventive
Services Task Force grades its recommenda-
tions. Available at: https://www.ahrq.gov/
professionals/clinicians-providers/guide-
lines-recommendations/guide/appendix-a.
html. Accessed 1 August 2019.
15. Lewis EL, Dolwick MF, Abramowicz S,
Reeder SL. Contemporary imaging of the
temporomandibular joint. Dent Clin North
Am 2008;52:875–890.
16. Hunter A, Kalathingal S. Diagnostic im-
aging for temporomandibular disorders and
orofacial pain. Dent Clin North Am
2013;57:405–418.
17. Delbalso AM. Anatomy of the mandi-
ble, temporomandibular joint, and dentition.
Neuroimaging Clin N Am 1998;8:157–169.
18. Ory PA. Interpreting radiographic data
in patients with RA. Ann Rheumat Dis
2003;62:597–604.
19. Gulsahi A. Osteoporosis and jawbones
in women. J Int Soc Prev Community Dent
2015;5:263–267.
20. Malliari M, Bakopoulou A, Koidis P. First
diagnosis of rheumatoid arthritis in a patient
with temporomandibular disorder: a case
report. Int J Prosthodont 2015;28:124–126.
21. Brooks SL, Brand JW, Gibbs SJ, et al. Im-
aging 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
2007;83:609–618.
22. Dahl HC, Parks E, Campbell JH, Stucki
DS, Daggy J. The utility of panoramic radiog-
raphy in temporomandibular joint assess-
ment. Dentomaxillofac Radiol 2005;34:9–15.
23. Dahlstrom L, Lindvall AM. Assessment
of temporomandibular joint disease by pan-
oramic radiography: reliability and validity in
relation to tomography. Dentomaxillofac Ra-
diol 2006;25:197–201.
752
24. Farkhondeh A, Geist JR. Evaluation of
web-based interactive instruction in intra-
oral and panoramic radiographic anatomy.
J Mich Dent Assoc 2015;97:34–38.
25. Mozzo P, Procacci C, Tacconi A, Martini
PT, Andreis IA. A new volumentric CT
machine for dental imaging based on the
cone-beam technique; preliminary results.
Eur Radiol 1998;8:1558–1564.
26. Cordeiro PC, Guimaraes JP, de Souza
VA, et al. Temporomandibular joint involve-
ment in rheumatoid arthritis patients:
association between clinical and tomo-
graphic data. Acta Odontol Latinoa 2016;29:
123–129.
27. Tsiklakis K, Syriopoulos K, Stamatakis
HC. Radiographic examination of the
temporomandibular joint using cone beam
computed tomography. Dentomaxillofac
Radiol 2004;33:196–201.
28. Larheim TA, Abrahamsson AK,
Kristensen M, Arvidsson LZ. Temporoman-
dibular joint diagnostics using CBCT.
Dentomaxillofac Radiol 2015;44:20140235.
29. Manoliu A, Spinner G, Wyss M.
Quantitative and qualitative comparison of
MR imaging of the temporomandibular joint
at 1.5 Tesla and 3.0 Tesla using an optimized
high-resolution protocol. Dentomaxillofac
Radiol 2016;45:20150240.
30. Kretapirom K, Okochi K, Nakamura S,
et al. MRI characteristics of rheumatoid
arthritis in temporomandibular joint. Dento-
maxillofac Radiol 2013;42:31627230.
31. Larheim TA. Imaging of the temporo-
mandibular joint in rheumatic disease. In:
Westesson PL, Katzberg RW (ed). Imaging of
the temporomandibular joint. Vol I. Cranio
Clinics International. Baltimore: Williams &
Wilkins, 1991:133–153.
32. Honda K, Larheim TA, Johannssen S,
Arai Y, Shinoda K, Westesson PL. Ortho cubic
super-high-resolution computed tomogra-
phy: a new radiographic technique with ap-
plication to the temporomandibular joint.
Oral Surg Oral Med Oral Pathol Oral
Radiol 2001;91:239–243.
33. Zain-alabdeen EH, Alsadhan RI. A
comparative study of accuracy of detection
of surface osseous changes in the temporo-
mandibular joint using multidetector CT
and cone beam CT. Dentomaxillofac Radiol
2012;41:185–191.
QUINTESSENCE INTERNATIONAL | volume 50 • number 9 • October 2019
34. Zufferey P, Tamborrini G, Gabay C, et al.
Recommendations for the use of ultrasound
in rheumatoid arthritis: literature review and
SONAR score experience. Swiss Med Wkly
2013;143:w13861.
35. Ten Cate DF, Luime JJ, Swen N, et al.
Role of ultrasonography in diagnosing early
rheumatoid arthritis and remission of rheu-
matoid arthritis: a systematic review of the
literature. Arthritis Res Ther 2013;15:R4.
36. Savtekin G, Sehirli AO. Rheumatoid ar-
thritis in temporomandibular joint: a review.
Niger J Clin Pract 2018;21:1243–1246.
37. Sudol-Szopinska I, Cwikla JB. Current
imaging techniques in rheumatology: MRI,
scintigraphy and PET. Pol J Radiol 2013;78:
48–56.
38. Beadsmoore C, Newman D, Maciver D,
Pawaroo D. Positron emission tomography
computed tomography: a guide for the gen-
eral radiologist. Can Assoc Radiol J 2015;66:
332–347.
39. Lee JW, Lee SM, Kim SJ, Choi JW, Baek
KW. Clinical utility of fluoride-18 positron
emission tomography/CT in temporoman-
dibular disorder with osteoarthritis: compari-
sons with 99mTc-MDP bone scan. Dento-
maxillofac Radiol 2013;42:29292350.
40. Yun M, Kim W, Adam LE, Alnafisi N,
Herman C, Alavi A. F-18 FDG uptake in a
patient with psoriatic arthritis: imaging
correlation with patient symptoms. Clin Nucl
Med 2001;26:692–693.
41. Alavi A, Lakhani P, Mavi A, Kung JW,
Zhuang H. PET: a revolution in medical imag-
ing. Radiol Clin North Am 2004;42:983–1001,
vii.
42. Basu S, Zhuang H, Torigian DA, Rosen-
baum J, Chen W, Alavi A. Functional imaging
of inflammatory diseases using nuclear
medicine techniques. Semin Nucl Med
2009;39:124–145.
43. Lee YZ, Ramalho J, Kessler B. PET-MR
imaging in head and neck. Magn Reason
Imaging Clin N Am 2017;25:315–324.
44. Torigian D, Chon E, Schuster S, Hof-
heinz F, Rosenbaum J, Alavi A. Feasibility and
utility of ROVER software for 3D quantitative
image analysis of FDG-PET in patients with
diffuse large B-cell lymphoma [abstract].
J Nucl Med 2009;50:135.
45. Wassef HR, Colletti PM. Nuclear med-
icine imaging in the dentomaxillofacial
region. Dent Clin North Am 2018;62:491–509.
 Mupparapu et al

Mel Mupparapu Mel Mupparapu Professor and Director of Radiology, Penn Den-
tal Medicine, Philadelphia, PA, USA

Sophia Oak Dental Student, Arizona School of Dentistry and

Oral Health, A.T. Still University of Health Sciences, Mesa, AZ, USA

Yu-Cheng Chang Assistant Professor, University of Pennsylvania

School of Dental Medicine, Philadelphia, PA, USA

Abass Alavi Professor of Radiology, Hospital of the University of

Pennsylvania, Philadelphia, PA, USA

Correspondence: Professor Mel Mupparapu, The Robert Schattner Center, University of Pennsylvania, School of Dental Medicine, 240
South 40th Street, Philadelphia, PA 19104-6030, PA, USA. Email: mmd@upenn.edu

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