Which imaging techniques should you prioritize for TMD patients? Does a panoramic radiograph hold any value?

When should you consider taking a CBCT of the joints instead? How about an MRI scan for the TMJ?

Dr. Dania Tamimi joins Jaz for the first AES 2026 Takeover episode, diving deep into the complexities of TMD diagnosis and TMJ Imaging. They break down the key imaging techniques, how to use them effectively, and the importance of accurate reports in patient care.

They also discuss key strategies for making sense of MRIs and CBCTs, highlighting how the quality of reports can significantly impact patient care and diagnosis. Understanding these concepts early can make all the difference in effectively managing TMD cases.

https://youtu.be/NBCdqhs5oNY

Watch PDP223 on Youtube

Protrusive Dental Pearl: Don’t lose touch with the magic of in-person learning — balance online education with attending live conferences to connect with peers, meet mentors, and experience the true essence of dentistry!

Join us in Chicago AES 2026 where Jaz and Mahmoud will also be speaking among superstars such as Jeff Rouse and Lukasz Lassmann!

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways:

Imaging should follow clinical diagnosis → not replace it.
Every imaging modality answers different questions; choose wisely.
TMJ disorders affect more than the jaw → they influence face, airway, growth, posture.
Think beyond replacing teeth → treatment should serve function, not just fill space.
Avoid “satisfaction of search error” → finding one problem shouldn’t stop broader evaluation.

Highlights of this episode:

02:52 Protrusive Dental Pearl
06:01 Meet Dr. Dania Tamimi
09:04 Understanding TMJ Imaging
16:00 TMJ Soft Tissue Anatomy
21:04 The Miracle Joint: TMJ Self-Repair
24:26 The Role of Imaging in TMJ Diagnosis
28:15 Acquiring Panoramic Images
39:35 Guidelines for Using Different Imaging Techniques
41:26 Case Study: Misdiagnosis and Its Consequences
45:46 Balancing Clinical Diagnosis and Imaging
50:17 Role of Imaging in Orthodontics
53:18 The Importance of Accurate MRI Reporting
58:27 Final Thoughts on Imaging and Diagnosis
01:00:54 Upcoming Events and Learning Opportunities

📅 Upcoming Talks & Courses by Dr. Tamimi

🔔 AES 2026 Conference (Chicago):

Topic: “Telling the Story of Your Patient Through Imaging”
Focus: Understanding patterns in imaging and how they reveal the patient’s full clinical picture

💻 “How to Read a Cone Beam CT” Virtual Course (Concord Seminars)

If you enjoyed this episode, don’t miss out on [Spear Education] Piper Classification and TMJ Imaging with Dr. McKee – PDP080.

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcomes A, B, and C.

AGD Subject Code: 730 ORAL MEDICINE, ORAL DIAGNOSIS, ORAL PATHOLOGY (Imaging techniques)

Aim: To enhance clinicians’ understanding of TMJ imaging modalities, improve diagnostic reasoning, and empower dental professionals to make evidence-based imaging decisions for temporomandibular joint disorders.

Dentists will be able to –

1. Differentiate between panoramic radiography, cone beam CT (CBCT), and MRI for TMJ evaluation.

2. Identify the appropriate imaging modality based on specific TMJ diagnoses (e.g., soft tissue vs. hard tissue pathology).

3. Recognize the risks of under- and over-imaging and apply a diagnostic question-driven approach to imaging selection.

#PDPMainEpisodes #OcclusionTMDandSplints #OralSurgeryandOralMedicine

Click below for full episode transcript:

Teaser: We do need to make sure that our teeth are in an orthopedically stable situation. And you should never trust what you see in the mouth 'cause the teeth may fit beautifully. But if the condyles aren't seated properly in the fossa, then it's like basically having a house built on quicksand. And this is a big thing that I see a lot in orthodontic treatment and others, they're just thinking about, alright, let's fix these.

Teaser:
And they’re not paying attention to the foundation of the house. The teeth are the window dressing. You are not a carpenter, even a carpenter diagnosis. You need to diagnose your patient prior to doing anything to them, to figure out what really is going on.

Medicine, including dentistry is seven parts, diagnosis, two parts treatment planning, and one part execution. So if you get all that, those first nine parts wrong, you’re not treating the patient. You may be treating a symptom, putting a bandaid on something, but you’re not getting the full picture. But we’re really storytellers, we’re detectives and we are looking at the imaging to try to find the stories and the history that the patient can’t verbalize themselves.

Jaz’s Introduction:
In our day-to-day dentistry, we take bite wings, we take periapical, and if you’re lucky enough to have a panoramic or a CBCT machine, we may take some of those. But what do we do when we have that TMD patient, TMD, obviously being an umbrella term. Listen to a lot of the other episodes on this podcast.

Learn more about TMD and how we can help as general dentists. But the question we’re really going to explore in today’s episode with an absolute sensational guest, the author of this book right here for the audio listeners is Temporomandibular Joint and Sleep Disorder Breathing by Dr. Dania Tamimi. And let me tell you guys, you are in for an absolute treat in today’s episode.

Some of the analogies she uses and the ways to explain certain elements of TMD, like for example, the clicking joint or the posh way of saying it is disc displacement with reduction. And so many colleagues get confused with that part with reduction. They still have no idea what it means. I’ve spoken to board certified prosthodontists on the phone and even they have been confused about what this actually means.

And so what Dr. Tamimi does in this episode is gives you one word to substitute in a way that suddenly all of this makes so much more sense. All her analogies are brilliant and we will explore, does a panoramic radiograph have value? When should we be considering taking a CBCT of the joints instead?

And are there any special instructions when doing so? And when do we need to take an MRI scan for the TMJ? And a little bit of the spoiler alert. My experiences with the MRIs have been just crazy in the sense that the person who reports it, will make a huge difference to the diagnosis. Let me say that again.

If you send your patient for MRI of the TMJs, well done. You might have helped it. And for the certain patient, we may be getting closer to the truth or to diagnosis, but the report can be so shockingly poor in my experience that, that MRI report ends up being a waste of money. I’ve seen this a few times down in my short career so far, and we discussed that.

I confronted the radiologist, Dr. Tamimi, on why this is happening and she had a really good answer actually. So get those onions ready, Protruserati, lots of chopping to do as you listen to these gems.

Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. This is the first AES takeover every year the AES put on a show in Chicago around about the second, third week of Feb, and Dr. Tamimi is one of the guests. And so what we’re doing basically is we’re getting on these absolute superstars in the world of occlusion comprehensive dentistry to create these awesome and engaging podcasts, but also shine a light on the good work done by the AES. Our guest today, Dr. Dania Tamimi, is one of the speakers, and guess what?

Yours truly me and Mahmoud will also be speaking at the AES 2026 in February. Our topic is Occlusion Basics and Beyond. Basically, we wanna put something together for the younger colleagues and cover the foundations of occlusion that you can apply on Monday morning. But the AES has a reputation of actually being leading and at the cutting edge of comprehensive dentistry.

Let me just talk you through the lineup, right? So this is the Protrusive Dental Pearl, by the way, get yourself to AES 2026. Okay, well, I’m kind of kidding, but I’m kind of not. Okay. The real Protrusive Pearl behind this is don’t lose touch with the magic of in-person learning and the magic of conferences where you get to meet your peers. Online is great.

I’ve been a fan of online since I graduated, but I also mixed it with in-person events. Obviously, minus covid. If all you’re doing is going to in-person events, then you’re missing out a lot online. And if all you’re doing is sat in front of a laptop watching videos and webinars, you are really missing the true essence of dentistry, which is the people around you, the new and old friends that you get to see, and the connections you get to make.

And this is what me and Mahmoud loved a few years ago. We went to AES, we met our heroes in occlusion, and it’s absolute honor to be invited to speak. The theme of the conference is the evolution of the oral physician. It’s on Feb 18th and 19th, 2026, so that’s so Wednesday and Thursday. I just name a few of the speakers.

Okay. We have Mariano Rocabado talking about orthopedic stability. If you don’t know about Mariano Rocabado, he’s a big deal in the world of TMD. He’s a world famous physiotherapist from Chile, and really a pioneer when it comes to craniofacial therapy and physiotherapy and the temporomandibular joint. We then have Javier Vasquez talking about facial growth, development of functional aging and the foundations of joints, muscles, airway, and teeth.

I mean, it brings together all the systems. There’s nothing more comprehensive than that. Then it got THE Jeff Rouse, who will also be coming on the podcast as part of the AES takeover and his title’s really interesting. It’s shifting paradigms from mechanical to biological explanations of dental wear.

So we see tooth wear on a daily basis, so that is very exciting. We have Tracey Nguyen on proactive dentistry, the cost of watchful waiting. Look, in the UK especially, we like to watch things. Okay, we like to monitor and watch things, but at what point are we doing a disservice to our patients? So I really like that, especially with cracks, I’ve become more proactive with cracks over the years.

Not so much invasive or aggressive, just more proactive. The next speaker is our guest today, Dr. Dania Tamimi. And her title is so fitting with the podcast today, right? Her title for AES is Telling the Story of Your Patient through Imaging, and you’ll definitely catch glimpses of that from today’s episode. We then have a very clever chap called Jay Levy.

I sat next to him at lunch at AES, and honestly, one of the most intelligent people I’ve ever met, the title of his lecture is The Biotensegrity of Occlusion. Look, I either know if I should be admitting this or not, right? But I have no idea what Biotensegrity means. Maybe this is embarrassing, I don’t know, but you know what?

I can’t wait to find out. Biotensegrity, here we come. And lastly, we have Jeff Salzenstein, who’s a former pro tennis player, and he’s talking about mind matters, prioritizing mental and physical health for the oral physician. And so what the AES like to do year by year is have a non-dental topic, but something that’s made relevant to us as dentists.

So I just want to walk through day one and the next episode, I’ll walk you through day two. But if this sounds interesting to you, and it should be because you listen to Protrusive Dental Podcast, you’re probably interested in these topics, head over to aes-tmj.org and have a think about joining us in Chicago.

If enough of you tell me you’re coming, we’ll arrange some sort of like a protrusive get together. So me and Mahmoud are so, so excited. But let’s get to this main episode now with Dr. Tamimi and I’ll catch you in the outro.

Main Episode:
Dr. Dania Tamimi, welcome to the Protrusive Dental Podcast. So, so nice to have you here. I’ve heard so much about you. I’m excited to see you next month. Fingers cross all being well, and you are a podcast veteran. So welcome to our podcast now. How are you?

[Dania]
I’m very well, thank you. I’m very happy to be here and happy to be talking to you as well.

[Jaz]
For those who haven’t heard of you yet, tell us about your career so far. Tell us about your journey. Tell us about what gets you excited.

[Dania]
Oh, gosh. About me, I mean, other than Mom of three and all that stuff, ’cause like that’s central in my life. I am an oral maxillofacial radiologist. I’m a dentist just like you guys, and I’m trained in oral maxillofacial radiology.

I’m board certified by the American Board of Oral and Maxillofacial Radiology, and I’ve spent almost two decades now trying to figure out this TMJ thing. And I’ve been very lucky to have some really amazing teachers like Dr. David Hatcher and Dr. Ronald Auvenshine, who’s an anatomist. All dentists and these people and many others have basically shaped the way I think.

Shape the way I see imaging and as radiologists, you tend to think of us as the people who are trying to find pathology, get you outta trouble. But we’re really storytellers, we’re detectives and we are looking at the imaging to try to find the stories and the history that the patient can’t verbalize themselves.

So what gets me excited? Many things do get me excited, but when it comes to this stuff, this radiology stuff, what gets me excited and what gets me excited to teach imaging interpretation is the light in people’s eyes when they realize it’s more than just a static image.

It’s a chronicle of someone’s life. And through the patterns of bone trabeculation, through the morphology of someone’s face, you can see those patterns manifest. The patterns of movement, the patterns of function, the patterns of growth. And that tells you a lot about you’re patient that they cannot tell you in their words, you know? So, yeah. So that gets me excited. And I guess we’re here to talk about TMJ, so I’m very happy.

[Jaz]
Amazing. Well, I love that storyteller reference and allowing patients to verbalize it through the medium that’s presented and being a storyteller that I’ve never heard that, that I’m never gonna forget that.

That is wonderful. I mean, I have so many questions today to ask, and just so I know, I would’ve mentioned this, the intro, but this is part of the AES takeover. We’re planned to be speaking in February, 2026, one of the biggest stages when it comes to TMJ and occlusion. So very, very excited to build up excitement for that event.

At the end, I’ll ask you again to describe what you’re talking about at that event, as well as where else we can learn from you. But the place I wanna start with in this exploration of TMJ imaging with you is starting with, I guess, radiographs that dentists are most familiar with, which is 2D, and let’s go with OPGs, right? OPGs. Call ’em what you want because my first question to you Dania is, is there enough diagnostic value in OPG? To give you some context, in the uk obviously we have an international audience, but in the UK they will not accept a referral to the OMFS department without an OPG, even if my diagnosis is purely muscular, right?

And I have a fantastic mouth opening and I know that clinically there is no evidence of disc displacement and all these things, they will still reject your referral unless you have an OPG. What do you think?

[Dania]
Hmm. That’s kind of interesting. I’ve never heard that one before. Here in the states, the surgeons will just take anyone without, well, I mean, of course with the referral.

[Jaz]
This is the public route. This is the public referral route.

[Dania]
So, yeah, so I got it. Okay. I guess they want you to do your due diligence and make sure you rule out anything osseous. But I mean, when it comes to TMJ, that’s kind of shortsighted and for a community that kind of cares about, like, makes a big hoopla about cone beam CT and radiation, that’s kind of interesting to hear.

[Jaz]
Isn’t it just?

[Dania]
It is. And a big portion of TMJ disorders, many of these TMJ disorders are muscular, they’re extracapsular. There are things that reside outside of the area of the TMJ. Yes, you can have referred pain from other places. Like you can have referred pain from the sinuses, from the teeth, from the neck and whatnot.

But in the end, the diagnosis is more of a clinical diagnosis and that kind of makes me a little upset that they would expose someone to radiation for no reason, just to satisfy it, to tick a box, to satisfy that requirement.

[Jaz]
I was unsure how you were gonna respond to that. I’ll be honest with you, because as a radiologist, I would’ve thought that you would have a bias towards, yes, imaging more images, the better I was a little bit, and I’m happy for guests to disagree with me, but I’m so glad that you were also as feeling the same way that I was when these referrals get rejected.

Now dentists, most dentists will tick the box and get the OPG and send it to them. And get that referral done. I feel very uneasy about that. But then let’s just twist it a little bit. When the dentist, who most dentists, unfortunately, I dunno what it’s like in the states, but when a patient comes with a temporomandibular joint complaint, dentists often get a little bit nervous.

Like, for example, dentists will tell me, hey, Jaz, I had a patient who had TMJ, they’ll call it TMJ, patient had TMJ and they had canine guidance on the left and group function on the right. That that’s kind of a descriptor I’ll get from the dentist. And then the next thing like, I’ll take an OPG. And so where does that come in, in terms of the decision making and when is it appropriate?

[Dania]
Gosh, you have to really, this is multifaceted. You really have to think about this, first and foremost. Okay, so I’m a radiologist, so I am, as you said, you’ve thought correctly. I am biased towards imaging because that’s my job.

But I’m also, I have enough knowledge about imaging indications, contraindications, pros and cons and things like that. In addition to a healthy respect for radiation, but I also have a healthy respect for getting the right diagnosis, because if you don’t get the right diagnosis, then you’re not treating your patient.

It just boils down to that, you need to have the correct diagnosis in order to come up with the correct treatment plan and execution of that treatment plan. Medicine, including dentistry, is seven parts diagnosis, two parts treatment planning, and one part execution. So if you get all that, those first nine parts wrong, you’re not treating the patient.

You may be treating a symptom, putting a bandaid on something, but you’re not getting the full picture. And you’re not treating that person. And unfortunately, as you know, in healthcare, and I’m sure it’s the same where you are, things are pretty disjointed, no pun intended. People tend to specialize and sub-specialize and have extra, extra specialization in interest in certain things that they get tunnel visioned.

And you get to just see that thing that you’re interested in and everything else blurs out. And that is a big problem. And when I teach people to read radiographic imaging, regardless of what that is, I tell them, here’s what you need to do. First thing is lose the tunnel vision. Okay.

And what that is is and that comes from our biases. We’re trained as dentists. We like teeth. If I like shoes, I would look at shoes. If I liked handbag, I would look at handbags. When you meet someone with class three caries, you can’t help but think of a spoon excavator going into that soft caries, right?

Or round bur or whatever you’re doing the procedure in your head. You can’t help yourself. If you’re an orthodontist, you’re classifying people, right? Class one, class two, class three. So what it boils down to radiographic imaging and the choice of what image needs to be obtained. It boils down to the diagnosis.

So a clinical diagnosis, and let’s talk about an ideal world where insurance and NHS and all these things don’t exist. You diagnose the patient, you have to see your patient first. And I know that this doesn’t fall into many assembly line clinic forms that we have in in the world right now where tick, tick, tick, get to the next patient, you know?

But the right thing to do is to diagnose your patient clinically first. Figure out what they have clinically, and then choose the appropriate imaging for it. It may be no imaging, if it’s a muscular temporomandibular joint disorder, it’s going to require no imaging. If it’s, for example, trigeminal neuralgia, you’re not gonna be doing a pano for that, right?

It’s gonna require an MRI, because that’s a soft tissue kind of thing. You need to figure out what’s going on in terms of like the trigeminal nerve and all the vessels that surround it, if any. Right? And if you decide it’s a sinus issue. Then that’s gonna be another set of radiographic imaging. It’s different for every single indication, every single diagnosis.

And I also understand that not everybody has access to the toolbox. We have a big toolbox in imaging. In dentistry, we have our plane films, we’ve got our Cone Beam CT, we’ve got an MRI, some people have ultrasound as well. Not everybody has access to all that. So sometimes we just have to make do with what we have.

But if we do have access to the toolbox, then we have to think about what is the best thing for this patient. Now, when it comes to TMJ, if you decide that it’s an intracapsular disorder, then you have to think, is it a heart tissue or a soft tissue kind of situation? Because if it’s soft tissue, MRI is the way to go.

And if it’s heart tissue and you determine that through clinical examination, and also viewing what’s happening in the face, the bite changes, the mandibular symmetry, the growth of a mandible, that sort of thing. Then you’re gonna need heart tissue imaging, three dimensional heart tissue imaging and Cone Beam CT would be the way to go.

[Jaz]
Can you explain more about the soft tissue for our younger colleagues who may not be familiar or remember the anatomy class they had some years ago about TMJ?

[Dania]
Oh gosh. The intracapsular soft tissue, right?

[Jaz]
That’s right.

[Dania]
Oh, this is gonna be hard for the audio people to listen to, but I’m gonna try to describe it as much as I can. So you’ve got a condyle, I’m gonna just hold my hand up here if you guys wanna watch those audio people while they watch this later in my head. That’s the condyle right there. And then you’ve got the fossa. So you’ve got two rounded surfaces against each other. And the place where the height of maximum curvature of those two rounded surfaces is an area of constriction.

And that’s where the thinnest part of a bow tie, which is what the disc looks like, sits, right? So the disc looks like a disc. Like if you take it out of a cadaver or a human, like another person, a normal disc looks like a disc, it’s an oval and it’s circumferentially thickened. But when we cut this in a cadaver, or cut it in MRI, you’ve got a posterior band, which is thick, and then you’ve got an anterior band, which is thick, and then you’ve got the intermediate zone, which is thin.

Think of a red blood cell. Take that red blood cell and cut it in half. That’s what it’s gonna look like on MRI. Okay, in that sagittal cut. Now, in order for the joint to function properly, all the components need to be sitting in the right place. Okay? So this is a very high loading joint, right?

Your condyle is an osseous surface. The fossa and the eminence are also osseous surfaces. What sits in between those two and what cushions these two is that disc, that red blood cell, right? Shaped thing. The bow tie, right? So now this disc has the ability to dissipate a lot of the loading has the ability to get rid of all the majority of the loading if the person is functioning properly.

But it’s a material and all of us have studied material science and dental school and everything in the world around you is a material, right? And your disc is a material, and your bones are materials. And every single one of those components have limits, have thresholds. So if you surpass the threshold that this disc can function at, then it starts to break down.

It’s made out of collagen. There’s a lot of collagen. There’s water as well. And if you just load it too much, it will break down. It’ll change shape and it’s no longer gonna fit nicely in that configuration that I talked about. Think of a jigsaw puzzle.

The disc sitting in between those rounded surfaces like a jigsaw puzzle fitting perfectly. And then just imagine your dog chewing up that disc part of the jigsaw puzzle. Try to fit it back in. You won’t be able to. All right. And it so that disc doesn’t fit in that area and it’s all mangled and it cannot stay in the place where it can protect those osseous components.

So that is an internal derangement and disc displacement. Okay, so disc displacement, you guys have probably heard of reduction and without reduction and that is just confusing. Like heck, the terms reduction make people like, I think go cross-eyed. Alright. So reduction can be very confusing for people, especially, in our minds, if we’re not medical, when we first start as dental students, whatever, we have an idea of what reduction is in the real world, which is basically the subtraction of something, making less of something, something that you make in the kitchen with red wine, poured out over some meat, that kind of thing.

And so it’s hard for you to conceptualize what reduction means. TMJ and unfortunately in our dental school programs, they don’t do a very good job of explaining it to us. Okay, what is this reduction thing? So I’m going to just give you a word to replace reduction with, and then everything’s gonna be clear.

Recapture. So when you have a disc displacement with recapture, as the condyle rotates forward and slides forward, it will snap back onto the disc and it’ll move. The two will move forward together, and as the condyle goes back into the fossa, the disc slips off again. Okay. So that is with recapture or with reduction.

[Jaz]
Okay. I love it.

[Dania]
Alright. And then that can progress as more morphologic changes happen to both the condyle and the fossa and the disc. There will be no recapture. So as the condyle moves forward, it doesn’t recapture the disc and there is disc displacement without reduction or without recapture.

In the beginning of that, when that first part of disc displacement without reduction occurs, there is a closed lock, there’s a mechanical inability to open the mouth, okay? But with time, the TMJ, which it by the way stands for the miracle joints, will fix itself, will regain range of motion.

So you may have noticed a little click when there was recapture. That’s the clinical symptom for that. And then when there’s no recapture, there’s no click. Your patient may be already at that end stage, disc displacement without recapture, and have full range of motion and no clicking and popping, but they have a compromised disc, a compromised TMJ, because that disc is supposed to be the cushion for the bones.

Now what happens to the bones? After not being cushioned for a while, they’re gonna start to change shape, and they’re gonna start to remodel and flatten out. Instead of being two rounded surfaces against each other, they rub against each other. It’s called Eber Nation, where bone starts to flatten out as two bones rub against each other.

They become parallel to one another. And then the bone is also a material. And when the bone can’t take it anymore, it’s gonna break down. And that’s gonna look like erosions low density areas in the articular surface of the condyle, and also the fossa, which will eventually heal itself and remodel. Okay.

And repair itself. The miracle joint will repair itself to bring you back to function. Okay? Now, there are consequences to this. There are consequences to the destruction of the condyle, which by the way, is a very important factor in the growth of your face. And if your TMJ is compromised before your face stops growing, then you have facial growth problems.

You have asymmetries, or you have retrognathia. A lot of your class two patients are not class two because that’s the way they were conceived or not conceived, but that’s the way that they were wearing, the genetic makeup. It’s a consequence of a younger version of degenerative joint disease called idiopathic condylar resorption, which I don’t like the term, but that’s what they call it. Okay.

Now what is all this? This whole thing is a continuum, right? The soft tissue destruction, followed by the heart tissue destruction, followed by the repair. In the end, the miracle joint will repair itself so that you can come back to function because you need to do a lot of things with your mouth.

You need to eat, you need to drink, you need to breathe. If your nose gets clogged up, you need to speak and communicate, and if your joints don’t work properly, you won’t be able to do any of that. So I believe in God, and I believe that he created this so that in a way that we can still regain function and still maintain our lives after the destruction of our TMJs, unlike any of the other joints that need to be replaced.

When they’ve gone whack. The TMJ rarely needs to be replaced after degenerative joint disease. So I think we need to circle back to imaging, right? Because like you were asking yeah. So, which-

[Jaz]
I mean, I just wanted to just clarify the importance of what you said there for our colleagues listening, because I still meet so many dentists who believe that when the click happens, that’s the disc moving out of position.

That’s the wrong thing is quite the opposite. Like you said, I know you summarize it beautifully with that word recapture and substituting that word reduction to recapture has helped hundreds of dentists finally get it. Because you’re right, reduction is a very confusing term. So that’s a real pearl right there.

[Dania]
Right. So now what imaging do I use? Okay.

[Jaz]
Essentially the crux we’re going then is, okay, so where do OPGs come in? Where do cone beams come in? Where do MRIs come in? I know we talked about countries having difficulties and access, but an ideal world through you, through your eyes and through your mind. What we can develop some indications and ideals.

[Dania]
Absolutely. So if you’re looking, like I said before, if you’re looking for soft tissue changes like this disc displacement with reduction, without reduction, some other intracapsular changes that I won’t have time to really talk about much today. Those need to be looked at with MRI.

An MRI is not a negative CT. It’s not a negative cone beam CT. There’s a technology behind it that helps us visualize fluid and fat, which is a big component of what we’re looking at here when it comes to the anatomy that we have. Especially in a world of the TMJ. So, yeah. I don’t wanna get too much into MRI technology unless you want me to, you know?

[Jaz]
No, I think we can go over the broader indications and that’s better. I think.

[Dania]
The point that I’m trying to make throughout all this is that with the destruction of the TMJs, there are gonna be downstream effects. There are gonna be downstream changes to the face. There are gonna be downstream changes to the occlusion.

There are going to be downstream effects to the airway because of the nature of the connectedness of your occlusion in the TMJs. You don’t just have two joints at the TMJs. You’ve got all these other joints, which are not synovial, which are the teeth as they come together. You’ve got heart surfaces coming together and functioning in against each other, and they are related to your TMJs.

So if your condyles are reduced in size, then with that reduction of size, that creates a space in your joint space. Just imagine, if you were to take a condyle, whatever it is, you know that that condyle is chopped off from top, you know? So the space that that condyle inhabited is now going to be wiggle room.

And it’s not chopped off, but the destruction that I just described here with the erosion, the active destruction of the bone, secondary to biomechanical extra, extra loading and inflammation and all that, that creates wiggle room. And this wiggle room is orthopedic instability. So your joints need to be orthopedically stable, and if the condyle is out of the fossa, then there’s a high likelihood of that condyle sitting back into the fossa and changing the occlusion.

If it happens on both sides and both condyles move upwards, then the bite opens up in front. If it happens on one side, then you can have a contralateral open bite on the other side and you can have occlusal cans and all kinds of things occur. So, so tying it back to dentistry, we do need to make sure that our teeth are in an orthopedically stable situation, and you should never trust what you see in mouth ’cause the teeth may fit beautifully, but if the condyles aren’t seated properly in the fossa, then it’s like basically having a house built on quicksand.

And this is a big thing that I see a lot in orthodontic treatment and others where they’re just thinking about, all right, let’s fix these. And they’re not paying attention to the foundation of the house. The teeth are the window dressing. And you don’t put the window dressing up before you build the foundation and the walls and all that. And the foundation and the walls would be the TMJs and the airway.

[Jaz]
I love that you described the teeth as joints. That was really nice. And it reminds you, everything you said there really reminds me of something that Jim McKee said on this podcast for think not how the occlusion affects the joints. Think how the joints affect the occlusion. And I think when people really understand that, that’s the next higher level thinking of occlusion beyond the teeth.

[Dania]
So now let’s tie that into the imaging. When you acquire a panoramic image, which you guys call it OPT or an OPG, right? What do you do with the teeth? How is that acquired?

[Jaz]
Use your cotton roll or the little plastic stick.

[Dania]
You use a bite stick. So what happens with the TMJs if you come into protrusive.

[Jaz]
It’s translate or pretend to translated right?

[Dania]
They’re gonna move forward, right? So you’re not gonna capture the joint space. You’re not gonna capture the relationship between the condyle and the fossa. You won’t be that. That’s a very integral part of your diagnosis. And yes, there are clinical ways to evaluate for orthopedic instability, but when you have the entire craniofacial complex in one view. Like you do on Cone Beam CT with the teeth together, which you can’t get with a panel because you need to have the mandible in Protrusive in order to capture the jaws in that focal trough.

If you go back to your pano textbooks, whatever, you’ll understand that’s how panels are acquired. There’s a focal trough and everything outside of this blurred, and if the things aren’t in the focal trough, then they’re gonna be blurred. And that’s why we bring the mandible into protrusive to make sure that we can see all the teeth and in the jaw.

‘Cause the lower jaw is usually a little bit inset. So we bring it forward in order to bring everything into the same focal trough. So another thing that the panoramic image isn’t really great at, other than, looking at that orthopedic stability, the position of the condyle in the fossa is the actual morphology of the condyle.

Okay. So when you think of the condyle, it looks kind of like a spatula. If you look at it head on, right. It’s rounded on the top. And like if you look at it anterior posteriorly, it’s rounded on the top, you know? And then it’s got a thin neck, so kind of tapers in, like right now, if you turn that spatula to the side, usually a spatula has a little rin to it.

Okay. Now that spatula isn’t aligned completely medial laterally on a pano. Because the nature of the projection geometry here, because of the way the pano is created, what tends to happen is the lateral pole moves down and forward. So this is what you’re looking at for those who are in audio, if you wanna come back to the video, this is what you’re looking at.

You’re looking at a distorted view of the condyle on your panels, not the true medial lateral dimension like you can with the cross sections that you get in on Cone Beam CT . And also, you’re not gonna be able to pick up the erosions, the erosions that are indications of early active degenerative joint disease or inflammatory arthritis.

And that diagnosis is super important before you start working, because you don’t wanna be working on someone who has active degenerative joint disease because through the changing of your biomechanics, the biomechanics of the patient, you can actually create more of a problem. You can create a greater magnitude of destruction in that area of the condyles.

So the inflammation, it’s inflamed, you’re not gonna pour fuel on the fire, you just wanna let it be. You don’t wanna start moving teeth or doing orthognatic surgery or anything like that. If somebody has an active disease process, active degenerative joint disease process and these erosions, when they’re small, you really can’t see them on Cone Beam CT.

And in fact, many times you can’t even see the big ones because of all that projection, geometry, distortion, anyway, so pano, okay, if that’s all that you have, that’s all that you have, but then the ideal way to to image for osseous change, in my opinion, is using Cone Beam CT. And I’m not gonna just say, okay, just get a cone beam CT of the TMJs, like one small one on the right, one small, one on the left, because then you’re just getting the anatomy, right?

This is the functional joint and the place of interest for you as a dentist is the teeth, and you need to know how these two are related. Are the teeth in maximum intercuspation during the acquisition of the Cone Beam CT? That’s a very important thing to know prior to interpreting the joint space of your condyles, when you’re looking at their imaging right, so the teeth in maximum intercuspation is important.

And also acquiring a field of view that encompasses, I mean, in my opinion, everything from glabella down to hyoid so that you’re viewing this craniofacial complex as a whole. There are downstream effects of temporomandibular joint disorders to the mandible, but also also to the growth of the face, the growth of the airway and position of the neck. How much space you have here. And I know not that too many people are on the airway, bandwagon, but you know, what’s the most important thing to-

[Jaz]
Well, the people with your face, listen, this will be, especially those who come into AES and subscribe to this, we are speaking to the converted in a way.

[Dania]
What’s the most important thing that you’re gonna do with your face?

[Jaz]
Breathe.

[Dania]
Breathe. Try not breathing for two minutes. You cannot eat or drink for whatever you, there is an alternative, IV whatever for nourishment. But breathing, that’s it. Well, unless you do like a trichotomy or something, who wants to do that, right?

But the way that your face forms is very highly related to the function of your TMJ and your jaws. So you need to look at all of that together and determine the patterns of change the story in the patient’s scan by looking at the whole thing together. And part of my frustration when I get scans from Europe, is those small fields of view.

One here and one here. I’m like, okay, I’ll tell you what the condyle looks like and where it is, but I can’t tell you if it means anything to you. And I can’t tell you if it’s doing anything anywhere else, you know? And sometimes even a condylar hypoplasia can be very subtle. And the only way you can tell it it’s a condylar hypoplasia is what it does to the rest of the mandible. Because the mandibles gonna follow the TMJ. And if the condyle doesn’t grow to full potential, the mandible doesn’t grow to full potential either. Anyway.

[Jaz]
So if you have a patient then who you suspect it is either degenerative joint joint disease, or it is osseous issue, and you’re requesting, you’ve laid out your guideline that you’d like cone beam, which shows more than just small views, you want encompassing so much more with that, and you want it in MIP or their teeth together, or at least the description of what position it is in. But then is that enough or do you need another one with a mouth open as well?

[Dania]
I don’t think that you would need an open Cone Beam CT. You can tell where the condyle is just by palpating. And that’s basically the information that the Cone Beam CT will give you. It’ll just tell you where the bones are in relationship to one another.

If you’re looking for things like, intracapsular changes the disc, whatever, that’s an MRI kind of thing, and that’s where you would get an open and closed. But I don’t think that an open is indicated. Now some people will argue with me and I’m gonna say, okay, if you really wanna do that, then get a small field of view.

‘Cause you don’t need to get a large field of view in the open view. You already have the anatomic information from the closed view in order to limit the imaging radiation to the patient. You can get a small one here and a small one there for that open view. But once again, I don’t think it’s important.

[Jaz]
Okay.

[Dania]
There is, I mean, someone once challenged me and said, okay, what about with coronoid hyperplasia, coronoid hyperplasia where coronoids are really large and we wanna see what they do with opening. I mean, sure. But you can tell that there’s a coronoid hyperplasia. You can tell how big it is, in relationship to the level of the condyle and whatnot.

So, I mean, what more is it gonna tell you? What is the imaging going to tell you? That’s a question you always need to ask yourself. Can I get the diagnosis without imaging? Okay, what is my question? What is the question that I want to answer? And if I can’t answer the question clinically, then I have to find another way to answer it.

Let me choose amongst my toolbox something that may have less radiation. So for example, I’m not gonna send a patient for medical CT because that’s a lot more radiation, but if that’s the only thing that I have and it’s really indicated and I can’t get the information any other way. And that’s the way it is.

Just yesterday I was working with someone who has, their patient goes through the VA system, veterans affairs system here in the US and the only way that they could get that reimbursed was to get a medical CT. And of course I’m like this, but it is what it is.

[Jaz]
I appreciate that. I think that’s a very honest, real world view of that. You have to work with what you have. So, so far we’ve covered Cone Beam CT and you gave us the guidelines in terms of don’t take it too small. We know we’re looking for osseous changes. We talked about soft tissue changes, intracapsular, we’re gonna go MRI.

Are there any situations where an OPG has value, therefore, like in a perfect world, if you have access to all this, are we suggesting that we don’t need an OPG ever, or I never say never, obviously, but that is a inferior choice. And you as a radiologist, once it gets to a point where the clinician’s unsure of a diagnosis and they need the imaging to help their clinical, that perhaps that doesn’t have as much value.

[Dania]
It’s a case by case kind of situation. It’s a case by case kind of situation. And I just have to say that, if you get a panel for let’s say for example, an implant case, you know that you’re gonna put a three-dimensional object in a three-dimensional object that has anatomy that you have to avoid.

So why do you get the panel to start with? It’s just using your mind, just use your brain. Think about what you’re gonna do in the long run. Let’s say it’s a surgeon who has impacted, wants to remove impacted third molars or partially impacted third molars and wants to see where the canal is.

Depending on where the level of the tooth is, if the tooth is slightly apparent in the oral cavity, maybe it’s far away from the canal and they don’t have to really worry about it. Let’s say that the teeth are fully erupted or partially erupted, but if the tooth is submerged, then most likely it’s gonna be close to the canal.

And then the question is, where is the canal in a relationship to the tooth? You know? ‘Cause like the canal can be going through the roots. It can be behind like lingual or a buccal or inferior, whatever. So it’s the level also the confidence of that surgeon that would maybe wanna do this with a pano, not get a Cone Beam CT.

And as we know, insurance also dictates this. They’re not gonna pay for a Cone Beam CT they’ll pay for a pano. And that’s what they have to what the clinicians have to contend with. My point is that if you clinically believe that a cone beam CT is indicated, you should not hesitate to get that as your first imaging, okay?

Don’t get the pano to just see what’s going on and then get the cone beam CT. Clinically, if you make the decision that the procedure that you’re gonna do is gonna require a three dimensional evaluation, you’re gonna be moving things in three dimensions. You’re gonna be removing things that may be impacted right in contact, compromising other structures.

Don’t fudge with the 2D. My opinion may not be popular, but as an expert witness in many malpractice cases, I’m just gonna tell you that the first thing that the lawyers do when things go wrong is put the patient in a cone beam CT to see if that whatever it is that was done wrong could have been avoided by getting three dimensional imaging versus 2D.

I hate to bring lawyers into this, but I know that’s not like forefront in many people’s minds.

[Jaz]
No, it’s true. Because we need to bear that in mind when we’re making decisions. And also get the right information to do justice for our diagnosis. But in terms of just a quickly about a CBCT.

Are the units that dentists have in their practice that are suitable for implants, usually suitable to get that level of imaging that you desire from condyle all the way down? Are the units that we have, are they adequate nowadays?

[Dania]
Well, there are different types of units. When you choose a unit for your practice, you have to look at your practice space. If you’re an endodontist, you’re not gonna need a large field of you. You’re gonna buy yourself a small field of view to just look at the area of the couple of teeth that you’re gonna be treating. And in the case of someone who, where you think that the pain is coming from elsewhere, then you can send them to an orofacial pain specialist.

An oral surgeon who may require a larger field of view. So that’s in case of the endodontist in case of the implant dentist. So your periodontist, oral surgeon implant versus people with affinity implants. Let’s put it that way ’cause I don’t think it’s a specialty yet.

[Jaz]
Correct.

[Dania]
But you know, okay. Implantologists, think about that, what that implant is. You are replacing a functional unit in a functioning being, in an organism. And that functional unit needs to work with all the other teeth and needs to also work with the TMJs. So you need to see what’s going on with the TMJs ’cause, like why would you do an all on four, for example, in the patient who has orthopedic instability?

You need to figure out if the condyles are seeded properly or not. Or if you’re gonna do even a bridge, you don’t wanna implant supported bridge three unit, whatever it is that you wanna do. You need to make sure that the occlusion is sound before putting these pegs that can’t be removed or not be removed, that they can’t be moved orthodontically.

They can be removed with a great deal of bone removal before you make that decision. And I’m just gonna give you an example here of a tunnel vision situation. It’s an expert with this witness case that I was involved in. So I’ll give you the story from the end. A patient shows up in the emergency room, this is the end, and I’m gonna tell you the backstory, okay? The patient shows up in the emergency room. He’s got an all on for supported denture. The surgeon in the emergency room doesn’t have the screw to remove the denture. The emergency was the patient had bit his tongue and it swelled up and he couldn’t breathe. So the surgeon decided, if I can’t remove this, then I’m gonna cut everything out.

And he removed the alveolar processes with the teeth. He was like working in an emergency kind of situation. Of course, me as an expert with this, I told them he could have done a tracheostomy, but whatever. But what’s the backstory of this patient who bit his tongue?

This patient was partially edentulous for a long time. He had front teeth. He didn’t have back teeth. And as you know, your tongue spreads when it doesn’t have support. It goes just like your feet when you’re in flip flops all the time. Like you’re in Florida. And so he had a big beefy tongue and then the general dentist decided that, talked him into an all on floor.

He extracted all of the front teeth or tear wood, whatever it is. So implant supported full dentures. And he didn’t put into consideration that his arches were narrow. He put the implants wherever the bone was. So by the time he put the implants and then the dentures, he’d crammed that tongue into a teeny tiny space.

So, of course, the patient bit his tongue. And it got infected, and then the rest of the story. But that first dentist wasn’t on the stand, it was the surgeon, obviously. But if you ask me, the fault came with poor diagnosis, just thinking tunnel vision, thinking of putting teeth in a person without looking at the whole situation.

So, going back to your question, you need to look at these people more fully. You’re not just putting implants in, you are replacing functioning teeth. And those functioning teeth need to follow the system, and you need to look at the integrity and the health of the system. Airway included, TMJ included, prior to putting these immovable pegs into people’s mouths and then, you know, them having to deal with the consequences of that.

So your question was, so are the TMJs visualized there? They should be. I mean, you shouldn’t be just getting one arch. You need to be seeing what that, you need to do a digital wax up. If not a conventional wax up, you need to do a virtual wax up. You need to see how the teeth fit with one another.

And you need to have to see how they fit with TMJs. So I don’t really advocate those single arch imaging for implants. ‘Cause it’s not about where the bone is. It’s about how it all fits together.

[Jaz]
And so in implant dentists would, when they’re dealing with patients, often older patients who’ve been through a lot more wear and tear to check for orthopedic stability of the condyles, is another important factor in their overall occlusal stability and their planning. Would you agree with that?

[Dania]
Yeah. You have to look at everything. Implant placement has been oversimplified for I believe for material gain in many places. The vendors want more dentists putting in implants. The patients want implants. The dentists wanna make more money putting in implants.

But it boils down to the importance of diagnosis. You are not just doing a mechanical procedure, you are not a carpenter, even a carpenter diagnosis, you need to diagnose your patient prior to doing anything to them. To figure out what re what really is going on. In the example of patients who, let’s say even a class one, class two restoration patient has a second molar class two restoration that he keeps breaking, and then you do an amalgam buildup and that doesn’t work out, and then you put a crown and then he splits the tooth. What’s going on here? It’s not that too, there’s something mechanically wrong and you’ve gotta figure that out.

[Jaz]
You got to think bigger picture.

[Dania]
So, yeah.

[Jaz]
With the CBCT, I wanna ask you about timing, and this is a really important question, and I’m happy to tell you at the level I’m practicing and I’m always happy for my guest to scrutinize me, criticize me in any way.

I’m always happy to learn, but I’m just gonna tell you what I do and my philosophy on imaging and with my experience so far, when I have a good history and a thorough clinical examination, and I have arrived at my differential diagnosis or a diagnosis that, you know what, I’m fairly happy with this diagnosis, and I don’t think I need imaging with that level of confidence I have for my diagnosis of the various different diagnoses with TMD being an umbrella term.

And if I have diagnosed, let’s say, a unilateral disc displacement without reduction or without recapture, without limited opening. So this patient can’t open normally the role of imaging then, in terms of, some of the previous guests, to give you some more context Dania, some of the previous guests I’ve had on. One has been a maxillofacial surgeon who’s not that keen on imaging at the forefront because he says, if I can make my diagnosis and I’m choosing that, I don’t think we need to do surgery here, then I don’t need the imaging ’cause I’ve got a good diagnosis.

Whereas I’ve had someone else on the show and they’re like, every patient needs an MRI, not every patient, but if you suspect any sort of disc derangement equals MRI. And so there’s a spectrum, right? And so where would you lie in the spectrum in terms of relying on your clinical diagnosis and then if the imaging is not really gonna add much or change much, when does it come in?

So to the bottom line is, when do I do it? If something’s not going right, if I’m like, hmm, I’m doubting myself. Hang on a minute. Is my diagnosis correct? Or I’m not sure of my diagnosis from the outset, that’s when I reserve imaging. What do you think?

[Dania]
Well, exactly what you just said, and I think I kind of alluded to it in the beginning, what’s the question that you want to answer and what are you gonna do with the answer? You see, because just like this oral surgeon said, if I’m not gonna do surgery, if I’m pretty sure with my diagnosis and I don’t see changes occurring, and I can treat this without using imaging, I will, right? I can. But people tend to be lazy, tend to get lazy, say, okay, I need this whole spectrum of stuff because I need to make sure that everything is okay.

And you know what? It’d be wonderful if we could do that. It would be wonderful if there wasn’t a radiation tax to pay and there wasn’t an actual monetary tax to pay as well. Because many of us, we rely on insurance to pay our things and they can deny it and then it can get very expensive, especially here in the US it’s very expensive, okay?

So it really is a case by case kind of situation. And what I would recommend to everybody listening, you included, is you just have to hone in on your diagnostic skills and broaden your mind and broaden your knowledge base. Because even with a clinical diagnosis, your eyes will only see what your mind knows.

And if you’re indoctrinated like with a certain philosophy and you’re only doing it that way and you’re not looking at it in the big picture kind of thing, you’re only gonna see it through that lens. And that’s not how human beings work, you know? Everybody is different.

Everybody has a different story to tell through their bodies, through the patterns of movement, through their patterns of function, through their whatever’s going on in their head, psychologically, whatever. As we know, there’s a lot of psycho stuff going on with TMJ too, right? The psychosocial component to that.

So we really do have to take a step back and diagnose our patients and learn more about how to diagnose our patients differently from other practitioners and step away from our ego. Stepping away from the ego, I think is the single most important thing a healthcare professional can do, because then if you believe that there’s another way to do things, your mind starts to grow.

Your mind starts to open up. So with that arsenal in mind, and if you don’t, can’t diagnose the patient properly, you have to step away from the ego and give the patient to somebody else. And then decide if imaging is indicated or it’s not. Once again, it’s about the question that you need to answer, and what are you gonna do with the answer.

Okay. I mean, you can do an MRI for every single person that walks in through the door, and you’re gonna find a big portion of them have clicking joints, have disc displacement with reduction or without reduction. So, but what are you gonna do with the information? Hey, yeah, it’s a nice little thing to add to their clinical diagnosis. But what are you going to do with this diagnosis? So that’s the question here.

[Jaz]
Okay. That was beautifully answered. That’s fantastic. Now, to give you a perspective of a radiologist that I’m very fond of in the UK, his MRI reports have been the best. And this is a two pronged question.

First is that, whilst I really respect this radiologist, he has this strong opinion that I want to just ask your opinion. All it is an opinion, but I’d love your opinion on this. He is of the camp that believes that any patient before orthodontics should have an MRI of their joints to confirm orthopedic stability prior to starting orthodontics. Okay. And so this is his belief. Where do you line that?

[Dania]
Yeah. There are many people who think different things. First of all, orthopedic stability is a clinical diagnosis. It can be verified or detected even with imaging. Okay. But the orthopedic stability, the wiggle room, is really a clinical diagnosis.

And there are different people who do it differently. Different people who will determine that differently. Whether you’re from the Dawson Camp or from the OBI or Face Group or whatever, Roth Williams, whatever it is. There are different ways to do this. It’s a clinical diagnosis that can be supplemented with radiographic imaging.

And in an ideal world, wouldn’t it be nice to have MRIs of every single person that comes through your door? But, we know in reality that’s not the case. And it’s gonna be hard, very hard to convince insurance or NHS to pay for it, because there is no standard of care when it comes to that.

Okay. I’d like to satisfy my curiosity and know where the disc is in every single person, but is that practical? I don’t think it is. Simply because there are too many things that come into the obtaining of an MRI, you know? Or obtaining of any kind of imaging and too much politics. So-

[Jaz]
I appreciate that real world view. I don’t think it’s always practical, but, I think what I took away from that is there is a time that we need to do our full history, full clinical examination, and then if we have a doubt prior to commencing something which is essentially full mouth rehabilitation in enamel orthodontics.

Or someone’s doing related work to then escalate to imaging is a very good thing, then therefore you can be a bit stronger in your recommendation. Whereas if you just did a blanket thing of, if you’re having ortho, if you’re having implants, which is a big deal, if you’re having a full mouth rehab, we better check your joints then, I think to do a full clinical diagnosis first to make to see whether the role of imaging is strengthened and to make it practical for your patient.

[Dania]
More importantly than the orthopedic stability that can be detected clinically is if there is active degenerative joint disease or not. And a cone beam CT is better for that than an MRI simply because of the voxel size, the resolution, spatial resolution and all that stuff that goes along with cone beam CT versus MRI. Okay.

[Jaz]
Well the second part of that question, Dania was that this radiologist, who I really admire gives brilliant reports. And unfortunately when I’ve had some patients come my way and they have an MRI report and I read it and I thought, hang on a minute, this is really not matching my clinical diagnosis at all.

Okay. And that’s not my ego saying, hang on a minute, I’m right here. Those few times I really doubted it ’cause it was such a strange one for me. And then I sent the images, the actual images to this radiologist, and the report I got back was completely different. And the quality was obviously much better, much thorough.

This is him being a brilliant radiologist. So I started to then do this a few times and I’ve been amazed at the level of, this is the UK, I dunno how it is in any other country, but I’ve been amazed at the quality of reporting. And so there’s image quality that comes into it and having the right equipment and stuff, which I don’t, we don’t get into, but there’s different MRI equipment, different centers, whatnot. And the quality of that varies as it naturally would, but also the interpretation of it will depend on your training. So have you experienced this as well?

[Dania]
The majority of the MRI reports that I write are rewrites.

[Jaz]
Wow. There we are.

[Dania]
Let me just give you like how things work in the US. Okay. So when you acquire an MRI in order for insurance to reimburse it, that MRI is the technical component. There has to be a professional component and the professional component is the report. So whoever gets the MRI like in the pile, of course now it’s not a pile anymore, it’s the list. Whoever gets it and reads it, gets paid for it.

Okay. Now if you’re lucky, a head and neck radiologist is gonna read it for you. If you’re not lucky, it’s gonna be a general radiologist, okay? My husband’s a radiologist, a medical radiologist. He’s a cardiac radiologist. And he says like in his entire residency, he maybe got one or two TMJ cases to read.

Okay. So unless you really care about this area and you really focus on it, then you’re not gonna really understand it. And even amongst the head and neck and neuroradiologist, they don’t get it like we do, like dentists do. They don’t understand what, all the stuff that I just explained to you, the occlusion and the facial growth and whatever.

I mean, I speak at the American Head and neck radiology meetings and whatnot and they, prior to my talks, They were talking about this morphologically. Where this in relationship to the fossa but the basic understanding of what all that means is kind of lost in the medical world. Now I’m saying there are a lot of good head and neck radiologists who dedicate their lives to learning the TMJ.

In fact, one of the pioneers in TMJ imaging was a renal guy. He just had an in. His name is escaping me right now. But God rest his soul. He passed away recently. Yeah. So if you go back and look at the literature back in the nineties. His name was all over the place. He was a medical radiologist who had a genital urinary radiology kind of practice, but he had an interest in the TMJ.

His name will come to me. I know after we talk, we stop talking here. So if you don’t dedicate the time to learn this, you’re not gonna be able to really interpret it. And unfortunately a lot of the education in the medical world also, the people who are teaching at TMJ don’t understand it.

Like we understand it. So they teach it, they propagate that same information or misinformation, okay? And I’m not saying I’m right, you’re wrong, whatever. Everybody has their opinion. But I’ve pretty much spent the past 20 plus years, trying to understand this thing and also understanding it from a perspective of a dentist, because I am a dentist and I serve dentists, right?

So when it comes to the choice of who to choose for, to read the scans for you, if you have an oral and maxillofacial radiologist, you’re golden. If you have a head and neck radiologist, you’re close to that. Depends on his understanding and how much he’s willing to invest in and learn, he or she, of course, learning more.

And I think a big part of it is your communication with them. And that’s the missing link right there is dentists educating medical people what they want and what they care about and what all this means to them and what they wanna see in their reports. Okay, so.

[Jaz]
I’m glad you said that really validates my experience in a way. ‘Cause for the first time I had this thought some years ago and I felt alone. I was like, am I being silly? And then to ask the patient to pay for the fee for the new report. So, you know what I did? I paid it out my own pocket.

‘Cause I was genuinely curious. And then that validated it. And then in the future, when I then got patients to get re reported, it’s amazing. And so that really taught me a lot. It taught me a lot. And so I gained a newfound respect for your field more than ever before. So it’s amazing what you do.

And I love everything you said today in terms of really bringing the patient into it. I think that is the beauty and the crux of it, rather than there’s just these images, is that storyteller analogy. Going back to the beginning. Any final points that you want to leave to a general dentist listening right now when they’re thinking about imaging for their TMD patients? Before we close off.

[Dania]
Listen to your patients. Take the time to listen to them. A big part of the TMJ disorder spectrum that they have is going to come from things that are going in on inside their heads. Okay. I believe in the psychosocial model as well as believe that the biomechanical model, maybe I’m a little bit, I’m on the fence, which is which, and I think that there are many little-

There’s a lot of interrelated stuff going on here. You can’t just say everything is psychosocial and you can’t say everything is biomechanical. You gotta talk to both fields and both, educate yourself in both camps. And then come up with what you feel is best for your patients.

And every patient is going to be different. You can’t treat people with a cookie cutter kind of approach, a cookbook kind of approach. It’s not like that. The most important thing is to listen. Okay. And observe and put your ego aside. And when you’re evaluating a patient, the last thing you want to look at is the chief complaint.

Chief complaint or the area of your interest. So look at everything else and then look at the chief complaint or the area of interest for you. Okay? If you’re an orthodontist or an implant, whatever, that’s the last thing that you look at. Because if you don’t do that, then you’re going to fall into the satisfaction of search error.

Satisfaction of search error is when you come up with the answer to the question that’s burning inside of you or burning inside the patient. Your brain checks out and you don’t approach the patient as pragmatically as you would’ve if you were to look at everything else first, and then the chief complaint, or-

[Jaz]
It’s really about being more comprehensive. And I think that really, really, describes you well.

[Dania]
Systematic and non-biased.

[Jaz]
Not so easy, if we have to really work on that as clinicians. That’s not so easy to do.

[Dania]
It’s the ego.

[Jaz]
It’s the ego. There we are. You’re so right. Dania, you’ve done a really wonderful job on a tough topic, so thank you from all of us at Protrusive for doing such a harmonious job and the way you explain and the whole thing about recapture, I think the penny really dropped for so many of our colleagues today. Can you tell us about your topic in Chicago, AES 2026? You know, I’m so glad to kick off the a s takeover series with you, but tell us about your talk.

[Dania]
Well, it’s gonna be called Telling the Story of your Patient through Imaging.

[Jaz]
Perfect.

[Dania]
And it’s basically understanding the whole system and looking at the patterns that are predictable and some not predictable, but looking at that through imaging, I mean, really cone beam CT has opened up a whole world of diagnosis for us and for us to poo poo it or to, to try to minimize its its importance in our diagnosis.

We’re no longer in the 1950s or the 1980s, we are in a new era where the diagnosis are evolving and our ability to diagnosis evolving, and we shouldn’t be afraid to use the correct diagnostic method for the patient who’s presenting to us at that single moment at this time. So that’s basically what I’m gonna be talking about, using the imaging to look for the stories and the bones. To look for the patterns in the bones and how all the moving parts come together and work together.

[Jaz]
Well, you are really part of a star studded lineup, and so we’re very excited to learn more from you in Chicago. So hopefully many colleagues will join us for that. You also said you do a fair bit of teaching. Is there anything that you help with dentists? How can we learn more from you? How can we connect with you?

[Dania]
Yeah, every other month I give a how to read a cone beam CT course online. So virtual, you can zoom in from wherever and it’s run by Concord Seminars. Okay. So Concord Seminars, if you look them up, you’ll find that there-

[Jaz]
I’ll add the link in the show notes for everyone.

[Dania]
Fabulous. Yeah. And I just do it for the dento-alveolar part because in order to do the whole thing, I did have a longer course, but it was just too much to sit for four days. So it’s a two day, half day kind of situation. So five hours, five hours, and it’s a time that works for pretty much every time zone. Not too late at night, not too early in the morning, something in between. I mean, people in Australia struggle, but-

[Jaz]
Aussies always struggle. God bless, right?

[Dania]
And I do have a book. I mean, I don’t know if you know anything about it or not.

[Jaz]
Yes, yes, yes. I’ve seen it. Special copy sign from you in Copenhagen. So I look forward to that. Well, fingers crossed that all goes ahead. And of course, again in Chicago. So thank you so much Dania, for giving up your time here to talk about something that you do so wonderfully. You know, when Bobby Supple was discussing with me about all the different guests you had planned and stuff, and you told me a bit more about you and he told me that you recently, I dunno, where you were teaching, was in Milan or something, I dunno.

And you got a standing ovation. I forget where it was that he mentioned. And so I can see why I, honestly, having this first experience of chatting to you, I can see why you are so respected and so keep fighting. Good fight. We are absolutely loving it. Please keep it up.

[Dania]
Thank you very much. It was such a pleasure talking to you and everybody have a wonderful day wherever you are in the world.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end. If you manage to listen, why not claim your CE credit? All paying subscribers to Protrusive can answer the questions.

Make sure you get 80% and we will issue your CPD certificate. We are a PACE approved provider. About 96% of our previous episodes are eligible for CE and we’ve also got a whole bunch of masterclasses and clinical videos are also eligible for CPD. So if you’re a returning listener or watch at a Protrusive, it’s well worth checking out our Protrusive Guidance network, home of the nicest and geest dentist in the world.

Head over to protrusive.app and we’d love to see you on there. Thank you so much again to our wonderful guest, Dr. Dania Tamimi. More to come as part of the AES takeover. Really excited to share with you the episode with Dr. Jeff Rouse coming very soon. And don’t forget to head over to aes-tmj.org to see if you could escalate this to the next step.

Can you now ask your spouse for permission to come to Chicago in February to learn more about comprehensive dentistry? I gave you a teaser of day one. I’ll give you a teaser of day two in the next AES takeover episode. Can’t wait to see you there. If you’re coming, let me know if you’re coming. DM me on Instagram or DM me on protrusive guidance.

Thanks again, my friends. I’ll catch you same time. Same place next week. Bye for now.

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