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Commentary |
1 Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710.
Received February 23, 2006; accepted after revision March 24, 2006.
Each month the American Journal of Roentgenology will republish
online one of the 100 most-cited articles from its first century. A
corresponding commentary in the print journal by a contemporary radiologist
will provide a current perspective. For a full list of these articles, see
page 3 of the January 2006 issue of AJR or go to
www.ajronline.org.
Keywords: arthrography • temporomandibular joint
Published in 1980, "Arthrotomography of the Temporomandibular Joint" was the first large series in the radiology literature to describe temporomandibular joint (TMJ) arthrography and correlate it with surgery [1]. The article generated tremendous interest for radiologists in an area that was becoming one of the hottest topics in dentistry and oral surgery. Diagnosing internal derangement of the TMJ, as it was called, became a considerable part of many radiologists' practice, with as many as five or six TMJ arthrograms obtained daily in many centers. Multiple additional articles on arthrography of the TMJ ensued. In subsequent years, CT of the TMJ began replacing the arthrogram in some centers, and currently MRI is used to image the TMJ for abnormalities.
The lead author on this article, R. W. Katzberg, is an academic radiologist and became an internationally respected authority on imaging the TMJ. He went on to become chair of radiology at a major teaching hospital in California. The second author, M. F. Dolwick, is an oral surgeon who was a pioneer in surgery on the TMJ disk and went on to become chair of the department of oral surgery at a major academic institution in Florida. My role was as a reluctant participant at first. TMJ arthrography took some skill and expertise that I did not initially possess, and it was a particularly painful procedure for many patients. Also, showing my lack of vision, I was certain this was an academic and clinical dead end. Nevertheless, I was persuaded to participate primarily because the authors needed an additional arthrographer.
I was the chief of musculoskeletal radiology at Wilford Hall Medical Center in San Antonio, Texas, the largest teaching hospital in the Air Force, and Katzberg was the chief of genitourinary imaging. We shared a small office, which gave him considerable opportunity to convince me that this area of imaging would enhance my career—he can be very persuasive. Once TMJ arthrography became the rage, I followed Katzberg's advice and became well versed in the field. This resulted in speaking engagements too numerous to count; multiple publications; and even a textbook devoted to imaging the TMJ, edited by Katzberg, Dolwick, and me that sold nearly 20,000 copies.
Within 10 years of this article's publication, during which time radiologists all over the world played a prominent role in assisting dentists and oral surgeons in diagnosing internal derangements of the TMJ, the role of imaging the TMJ nearly died out completely. The need for imaging seemed to be replaced by a good history and physical examination (imagine that!), and advanced imaging was relegated to the problem cases and some postsurgical cases. Today arthrography of the TMJ is virtually nonexistent. I have not seen a TMJ arthrogram in nearly 20 years. TMJ arthrography is not currently performed in conjunction with MRI as arthrography is in other joints. At Duke, we are asked to do a TMJ MRI about 6-8 times a year, whereas 15 years ago I would see that many in a week.
Was TMJ arthrography, as depicted in this article, a hoax? Was it an examination that was not really necessary—just a fad for radiologists? I am convinced it served a useful purpose in its day. It certainly helped oral surgeons to perfect their surgical techniques by showing the anatomy and pathology in affected patients. Why did it die out? I suspect because it became obvious to the experienced clinician that the diagnosis could be obtained without the need for a costly imaging examination. Early on, this was new territory for dentists and oral surgeons, and it took time for them to learn to rely on their own physical examination skills. In the meantime, imaging reinforced their findings. Also, many third-party payers would not cover the treatment for TMJ internal derangements without objective imaging evidence. That does not seem to be the issue today or we would still be imaging the TMJ in large numbers.
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