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24 June 2026

24 Pages

Beyond Teeth and Jaws: Non-Odontogenic Findings on Panoramic Radiography and Their Relevance to Dental Practice

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1
Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy
2
Vascular and Endovascular Surgery—Department of Emergency and Organs Transplantation, “Aldo Moro” University of Bari School of Medicine, 70124 Bari, Italy
3
Independent Researcher, 71019 Vieste, Italy
*
Author to whom correspondence should be addressed.
Appl. Sci.2026, 16(13), 6344;https://doi.org/10.3390/app16136344
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Abstract

Background: Panoramic radiography is one of the most widely used imaging examinations in dental practice, providing a broad view of the jaws and adjacent head and neck structures. Although primarily prescribed for odontogenic assessment, its field of view may reveal non-odontogenic findings with potential clinical significance. Methods: A structured narrative review was conducted according to SANRA criteria. A literature search was performed in PubMed/MEDLINE, Embase, Scopus, and Web of Science for English-language publications from January 2010 to May 2026. Backward and forward citation tracking of relevant articles, key reviews, and reference textbooks was also performed. Eligible studies and authoritative sources addressing non-odontogenic findings detectable on panoramic radiographs were qualitatively synthesized. Results: The review focuses on carotid artery calcifications, maxillary sinus abnormalities, mandibular radiomorphometric signs related to low skeletal bone mineral density, elongation or calcification of the stylohyoid complex, sialoliths, tonsilloliths, calcified lymph nodes, phleboliths, and laryngeal cartilage calcifications. These findings range from benign anatomical variants to radiographic indicators that may require medical or specialist evaluation. Conclusions: Panoramic radiography should be regarded as a tool for recognition and clinical suspicion rather than definitive diagnosis of extraoral or systemic disease. Dentists play a central role in systematically assessing the entire image, documenting relevant abnormalities, correlating them with patient history and risk factors, and initiating appropriate referral when indicated.

1. Introduction

Orthopantomography (OPG) is one of the most widely used imaging examinations in dental and orthodontic practice, as it provides, through a single exposure, an overall representation of the dental arches, the maxillary and mandibular bony structures, the temporomandibular joints, and several adjacent anatomical regions [1,2]. This comprehensive view supports its extensive use in the initial assessment of patients, treatment planning, and monitoring of various odontostomatological conditions [1,2]. However, because of its broad field of acquisition, OPG should not be interpreted as an examination limited exclusively to the teeth and jaws, but rather as a complex image that also includes anatomical areas where findings unrelated to dental disease may be detected [3,4,5]. From this perspective, systematic analysis of the entire OPG has clinical value that extends beyond the dentomaxillofacial field alone [3,4,5]. Indeed, OPG may reveal non-dental findings of variable nature and significance, including carotid artery calcifications, maxillary sinus abnormalities, radiographic signs suggestive of reduced bone mineral density, elongation or calcification of the styloid process, sialolithiasis, tonsilloliths, lymph node calcifications, phleboliths, and calcifications of the laryngeal cartilages [6,7,8,9,10,11]. Some of these findings correspond to anatomical variants, benign conditions, or calcified sequelae without immediate clinical relevance, whereas others may represent indirect indicators of extraoral or systemic diseases requiring further investigation [3,5,6,12]. It is therefore essential to emphasize that OPG cannot, in most cases, be considered a definitive diagnostic examination for non-dental diseases. The intrinsic limitations of this imaging modality, related to the two-dimensional nature of the image, anatomical superimposition, geometric distortion, and variability associated with patient positioning, require cautious interpretation of the observed findings [1,2,4]. In this context, the role of OPG is primarily that of a first-line imaging examination, useful for the incidental recognition of abnormalities, for guiding clinical suspicion, and for initiating, when appropriate, further diagnostic assessment through dedicated imaging examinations or specialist consultation [2,3,4,5,12]. In this regard, dentists may play a particularly relevant role not only in the diagnosis of oral diseases but also in the preliminary identification of radiographic findings that fall outside the strictly dental field. The ability to recognize these alterations, distinguish them from odontogenic diseases, and assess their potential clinical significance positions the dentist as a sentinel figure, potentially involved in the early detection of extraoral conditions of medical interest [3,5,6,7,12,13]. In light of these considerations, the present study aims to provide a narrative analysis of the main non-dental findings that can be identified on OPG, with particular attention to their radiological features, differential diagnosis, and potential clinical relevance. The objective is not to assign OPG an autonomous diagnostic value for extraoral diseases, but rather to highlight how a systematic, informed, and methodologically appropriate interpretation of the examination may contribute to the recognition of findings deserving clinical attention, while also providing practical guidance for their proper radiological assessment and for the possible referral of patients for targeted diagnostic investigation [1,2,3,4,5,12].

2. Materials and Methods

2.1. Study Design

This study was designed as a structured narrative review to identify, describe, and clinically contextualize non-odontogenic findings that may be detected on OPG in routine dental practice. A structured narrative review was considered more appropriate than a systematic review because the aim was not to answer a narrowly defined clinical question or perform a quantitative synthesis, but to provide a clinically oriented overview of multiple non-odontogenic findings detectable on OPG. Given the heterogeneity of the available literature in terms of study design, populations, imaging methods, and clinical outcomes, a qualitative synthesis guided by SANRA (Scale for the Assessment of Narrative Review Articles) criteria was deemed the most suitable approach [14]. The primary unit of analysis was the non-odontogenic radiographic finding identifiable on OPG. The findings were synthesized qualitatively and organized into predefined diagnostic categories relevant to dental practice.

2.2. Information Sources and Search Strategy

A literature search was conducted in PubMed/MEDLINE, Embase, Scopus, and Web of Science covering the period from January 2010 to May 2026. To maximize retrieval of relevant publications, backward and forward citation tracking was also performed on all included articles, key review papers, and major reference textbooks in oral radiology and head and neck imaging. Before the formal search, a preliminary scoping phase was undertaken to map the terminology used to describe non-odontogenic or extra-dental findings detectable on OPG and to identify the main categories most frequently addressed in the literature. These categories included, among others, carotid artery calcifications, maxillary sinus abnormalities, tonsilloliths, elongated styloid process and/or calcified stylohyoid complex, calcified cervical lymph nodes, osteoporosis-related mandibular cortical changes, and other soft-tissue calcifications of the head and neck, as well as the distinction between dental age estimation and skeletal/auxological age assessment. Based on this exploratory phase, and informed by standard textbooks and previous reviews, an a priori list of diagnostic domains was defined and used to guide the search strategy. Search strings were then developed for each domain by combining terms related to OPG, incidental or non-odontogenic findings, head and neck calcifications, maxillary sinus alterations, mandibular radiomorphometric indices, and related disease-specific terminology. The complete search strategies for each database are reported in the Supplementary Material (Supplementary S1).

2.3. Eligibility Criteria

Studies were considered eligible if they reported extra-dental findings detectable on OPG and provided information relevant to their radiographic appearance, differential diagnosis, clinical interpretation, prevalence, or implications for referral and patient management. Both studies specifically focused on incidental findings on OPG and studies addressing individual extra-dental entities identifiable on OPG were considered for inclusion. Publications primarily addressing odontogenic disease, dentoalveolar pathology, or jaw lesions strictly related to the teeth and their supporting structures were excluded unless they contributed directly to the differential diagnosis of an extra-dental radiographic finding. Animal studies and articles not published in English were also excluded. Because the purpose of the review was clinical and interpretive rather than quantitative, no restrictions were placed on study design. Accordingly, observational studies, diagnostic accuracy studies, case series, case reports, review articles, and authoritative reference sources were all considered when relevant to the topic. All radiographic images used in this review were derived from anonymized archival material; all patient-identifying information was removed, and consent was obtained when applicable according to institutional policies and regulations.

3. Non-Odontogenic Findings on Panoramic Radiography

3.1. Carotid Calcifications

Vascular calcifications located in the carotid region or along the course of the cervicofacial arteries are incidental but clinically significant findings that may be detected on OPG (Table 1) [15]. Several studies have reported prevalence rates of vascular calcifications on OPG ranging from 2% to 11% in adult populations, with higher rates observed in specific subgroups, including men, individuals over 40 years of age, smokers, patients with hypertension, diabetes, or hypercholesterolemia, and those who have undergone kidney transplantation or head and neck radiotherapy [16,17]. Carotid calcifications are the most frequent incidental finding in radiographs of patients over 60 years of age [18]. Several studies have suggested a relationship between carotid-region calcifications detected on panoramic radiographs and periodontal risk or poor oral health. Although this association does not establish causality and OPG cannot be used to diagnose vascular disease, it highlights the potential relevance of integrating radiographic findings with periodontal status and systemic cardiovascular risk factors during dental assessment [7,19,20,21].
Table 1. Carotid calcifications on orthopantomography: a summary of the literature from the last 15 years.
The OPG used in daily clinical dental practice has early diagnostic potential in the detection of radiopaque findings in the carotid region. Signs compatible with carotid artery calcifications visible on OPG appear as heterogeneous radiopaque nodular masses, localized in 78.22% of cases in the region of the carotid bifurcation, that is, in the area adjacent to the cervical vertebrae, at or below the C3–C4 intervertebral space, at a 45-degree angle to the mandibular angle (Figure 1).
Figure 1. Routine orthopantomography of a patient showing radiopaque formations at the left mandibular angle and C3–C4 vertebral level, compatible with carotid calcifications (green circle). The image is derived from anonymized archival radiographic material; all patient-identifying information was removed.
Calcifications may also be identified at the level of the carotid bifurcation, in the superior region of the external carotid artery along the course of the superficial temporal artery, or as multiple tortuous “tram-track” calcifications adjacent to the posterior border of the mandibular ramus, consistent with Mönckeberg arteriosclerosis involving the maxillary and facial arteries (Figure 2) [49]. Such superiorly located calcifications, as observed in these cases, have been associated with an increased risk of intracranial ischemic disease and are frequently reported in patients with chronic kidney disease [50,51,52].
Figure 2. Schematic representation of the course of the common carotid artery and its external and internal branches in relation to key landmarks on panoramic radiography.

3.2. Maxillary Sinus

OPG provides a broad overview of the maxillofacial region and allows simultaneous assessment of the maxillary bones and maxillary sinuses [53]. In dental practice, this imaging modality may contribute to the preliminary recognition of maxillary sinus abnormalities, particularly because several sinonasal conditions are asymptomatic and are detected incidentally during routine radiographic evaluation. Radiographic alterations involving the maxillary sinus may include mucosal thickening, polyps, mucous retention cysts, antral cysts, and neoplastic lesions (Table 2) [53,54].
Table 2. Main maxillary sinus pathologies observable on OPG.
These abnormalities may present with variable radiographic appearances, ranging from localized dome-shaped opacities to more extensive changes affecting the sinus cavity. Calcified radiopaque bodies with heterogeneous morphology may also be detected and are referred to as antroliths when located within the maxillary sinus and rhinoliths when located within the nasal cavity [6]. The prevalence of pathological changes affecting the maxillary sinuses ranges from 45% to 70%. Among these findings, mucosal thickening represents the most frequently reported inflammatory alteration, irrespective of its etiological origin. This finding may be odontogenic in 10–40% of cases or non-odontogenic in 5–12% of cases [62]. Odontogenic involvement is particularly relevant in dental imaging, as inflammatory processes arising from periapical infection, periodontal disease, endodontic pathology, or post-surgical complications may extend to the sinus floor and induce localized mucosal reactions (Figure 3) [3,63].
Figure 3. A clear oroantral communication is present in the region of the upper right first molar (blue arrows), associated with a recurrent odontogenic abscess. The image is derived from anonymized archival radiographic material; all patient-identifying information was removed.

3.3. Osteoporosis

Osteoporosis is a skeletal disorder characterized by progressive loss of bone mass, which predominantly affects older individuals and tends to occur earlier in women [64]. Early signs of osteopenia and osteoporosis may be detectable on OPG [65]. Over the past four decades, numerous studies have reported incidental radiographic findings on dental OPG that may be suggestive of the early stages of osteoporosis [64]. OPG may provide adjunctive radiographic information that can raise suspicion of reduced bone mineral density in selected patients; however, it should not be considered a standalone screening tool for osteoporosis, and any suspected finding requires confirmation by dedicated densitometric assessment. This can be achieved through the evaluation of mandibular radiomorphometric indices, including the number of missing teeth, alveolar bone resorption, lamina dura width, mandibular cortical thickness, and the morphology of the inferior mandibular cortex, commonly assessed using the mandibular cortical index (MCI) (Figure 4) [66].
Figure 4. OPG in which some mandibular radiomorphometric indices can be assessed: number of missing teeth, alveolar bone resorption, mandibular cortical width, and mandibular cortical morphology. The image is derived from anonymized archival radiographic material; all patient-identifying information was removed.
Trabecular bone is more sensitive to changes in bone metabolism than cortical bone [67]. For this reason, a more objective radiographic assessment may be obtained by evaluating mandibular indices such as the MCI, which describes the appearance of the endosteal margin of the mandibular cortex, and mandibular cortical width (MCW), measured at the region of the mental foramen (Table 3, Figure 5) [68].
Table 3. Mandibular radiomorphometric indices assessable on orthopantomography: measurement methods and clinical significance.
Figure 5. Mandibular Cortical Index and Mandibular Cortical Width on OPG: qualitative and quantitative assessment of the mandibular cortex.
The main advantage of these indices is that they may provide dentists with simple and cost-effective tools for the early detection of radiographic signs suggestive of osteopenia or osteoporosis. However, their diagnostic accuracy and clinical applicability should be interpreted with caution, as the demographic characteristics of the available studies are highly heterogeneous, particularly with regard to sex, age, and menopausal status [69].

3.4. Styloid Process

The styloid process is a cylindrical bony projection that arises from the temporal bone, anterior to the stylomastoid foramen. Its length varies considerably among individuals, between the two sides of the same individual, and across different populations. It also tends to increase with age, is commonly bilateral, and is usually clearly visible on OPG [70]. Langlais proposed a radiographic classification of elongated and mineralized stylohyoid ligament complexes based on three morphological types: Type I, elongated; Type II, pseudoarticulated; and Type III, segmented. These were further characterized according to the pattern of calcification as calcified outline, partially calcified, nodular, or completely calcified [71]. According to a 2022 systematic review, elongation of the styloid process may result from a chronic age-related calcification process, although it does not appear to be significantly associated with sex [72]. The normal length of the styloid process generally ranges from 20 to 25 mm, and it is considered clinically relevant when it is markedly elongated, typically exceeding 30 mm [73].
An elongated styloid process may remain entirely asymptomatic and therefore be detected incidentally on radiographic or tomographic examinations performed for unrelated reasons (Figure 6). In some cases, however, this anatomical variation may give rise to a range of symptoms, presumably due to compression or irritation of adjacent neurovascular and soft-tissue structures, particularly the cranial nerves, carotid vessels, and surrounding soft tissues. The most frequently reported symptoms include pain during head movement, cervicofacial pain, otalgia, headache, dysphagia, odynophagia, tinnitus, and trismus. This clinical spectrum is commonly associated with Eagle syndrome, a condition in which elongation or calcification of the stylohyoid complex becomes clinically significant [74].
Figure 6. Marked elongation of the styloid process (red arrows). The image is derived from anonymized archival radiographic material; all patient-identifying information was removed.

3.5. Sialolithiasis

Sialolithiasis is one of the most common obstructive disorders of the major salivary glands, affecting approximately 0.01% to 1% of the population [75]. It results from the deposition of calcium salts around accumulations of organic debris, including mucous substances, ductal epithelial cells, bacteria, or even foreign bodies, leading to the formation of so-called sialoliths [76]. The submandibular glands are the salivary glands most frequently affected by sialolithiasis, accounting for approximately 80% of cases. This predominance is related to the morphology of the salivary duct and to the alkaline environment, which is characterized by a high phosphate concentration [77]. According to a study that analyzed 500 OPG, sialoliths are often incidental findings, with a reported prevalence of 3%. Submandibular sialoliths were the most frequently observed and were more commonly detected in female patients, whereas parotid sialoliths were more frequent in male patients [78]. On OPG, sialoliths may be identified as unilateral, diffusely calcified radiopacities with well-defined borders, usually located below the mandibular margin and near the region of the mandibular ramus (Figure 7) [18]. However, the radiographic diagnosis of sialoliths can be challenging, as conditions such as osteosclerosis, enostosis, osteoma, phleboliths, and calcified lymph nodes may show similar radiographic features (Table 4) [6].
Figure 7. Sialoliths of the parotid gland (A) and submandibular gland (B) (red circle). The image is derived from anonymized archival radiographic material; all patient-identifying information was removed.
Table 4. Main differential diagnoses of sialoliths and overlapping soft-tissue calcifications on panoramic radiographs.
In the past, conventional occlusal radiographs were the initial diagnostic modality of choice. They were relatively effective in detecting large radiopaque ductal stones, but they were unable to identify smaller intraparenchymal stones, although approximately 80% of sialoliths are radiopaque [86]. OPG taken during dental examinations can detect sialoliths with good overall accuracy, but with limited precision. This limitation is mainly due to the distortion that frequently occurs in OPG and to the superimposition of anatomical structures in the mandibular body. Therefore, computed tomography is often required for an accurate diagnosis and for determining the exact location of the stone, particularly when treatment planning is needed [76]. The ability of dentists to identify sialoliths on OPG is essential in order to avoid confusion with other soft-tissue calcifications, which are very common in the head and neck region [78].

3.6. Tonsilloliths

Tonsilloliths are calcified concretions that develop within the crypts of the palatine tonsils, usually as a result of the progressive deposition of calcium salts on retained organic material, including cellular debris, food remnants, bacteria, and mucous secretions. In most cases, they represent benign and asymptomatic findings and are often identified incidentally on radiographs obtained for dental purposes. On OPG, tonsilloliths may appear as single or multiple radiopaque masses of variable size, typically projected over the mandibular ramus region, most commonly near the area superimposed on the soft palate and the oropharyngeal space [87]. From an epidemiological perspective, tonsilloliths show a generally low prevalence among patients examined with OPG, with a higher frequency reported in males [3]. Their radiographic detection depends on several factors, including the degree of mineralization, size, number of calcified deposits, and their spatial relationship with adjacent anatomical structures. Small or poorly calcified tonsilloliths may not be visible on OPG, whereas more heavily mineralized concretions tend to appear as clearly recognizable radiopaque masses in the mandibular ramus region. A relevant radiographic feature is the possible occurrence of ghost images or contralateral artefacts. Because of the anatomical position of the palatine tonsils relative to the focal trough of OPG, tonsilloliths may produce a double projection, consisting of a real radiopacity on the side of origin and a ghost image on the contralateral side. This phenomenon may complicate radiographic interpretation and requires careful assessment of the symmetry, margin definition, and location of the observed radiopacities [75]. According to the classification proposed by Oda et al., tonsilloliths detected on OPG can be divided into three regions in relation to the mandibular ramus and the soft palate: region 1, located superior to the soft palate; region 2, corresponding to the level of the soft palate; and region 3, located inferior to the soft palate [88,89]. This classification provides a systematic description of the topographic distribution of these findings and may facilitate their radiographic recognition, particularly when tonsilloliths appear as small multiple radiopacities or are superimposed on adjacent anatomical structures [89]. The low detection rate of tonsilloliths on OPG may be related not only to their morphological characteristics and degree of calcification but also to the inherent limitations of two-dimensional imaging, in which anatomical superimposition and ghost images may interfere with interpretation. Since these calcifications are frequently projected over the mandibular ramus region, they should be distinguished from other radiopaque findings in the same area, including bone islands, lymph node calcifications, phleboliths, sialoliths, vascular calcifications, and other mineralized soft-tissue lesions [89]. Accurate identification therefore requires combined evaluation of the location, morphology, number, distribution, and possible bilaterality of the radiopacities.

3.7. Lymph Nodes

Calcified lymph nodes may be detected on routine OPG as soft-tissue radiopaque masses of variable shape and size. Their radiographic appearance may be laminated or heterogeneous, with both radiopaque and radiolucent areas [6,82,90]. They typically present as single or multiple irregular and lobulated radiopacities of variable size, often with a characteristic cauliflower-like appearance, and are usually located along the submental, submandibular, or cervical lymph node chains (Figure 8) [18]. Lymph node calcifications may occur as a result of previous chronic inflammatory, infectious, granulomatous, or neoplastic processes. They have been described in association with tuberculosis and other granulomatous diseases, including sarcoidosis, histoplasmosis, coccidioidomycosis, and blastomycosis, as well as in lymphoma, thyroid and breast metastases, and systemic inflammatory conditions such as rheumatoid arthritis, scleroderma, and amyloidosis [91,92]. From a radiographic perspective, these calcifications should be distinguished from other soft-tissue radiopacities in the cervicomandibular region, including sialoliths, phleboliths, tonsilloliths, and vascular calcifications [83,84].
Figure 8. Panoramic radiograph showing multiple irregular and lobulated radiopacities in the left laterocervical region (green circle), consistent with calcified lymph nodes. The image is derived from anonymized archival radiographic material; all patient-identifying information was removed.

3.8. Phleboliths

Phleboliths are intravascular calcifications resulting from the mineralization of thrombi that develop as a consequence of slow or stagnant blood flow, particularly within venous vascular malformations or other low-flow vascular lesions [93]. On OPG, they are relatively uncommon findings, and their prevalence tends to increase with age [18,94,95]. Radiographically, phleboliths appear as round or oval radiopacities, either solitary or more commonly multiple, with variable size and an occasionally scattered distribution within the soft tissues. A characteristic feature is their laminated or concentric morphology, often described as a “target-like” appearance, with either a radiopaque or radiolucent center and variably defined margins [6]. From a differential diagnostic perspective, phleboliths may resemble sialoliths, particularly when projected over the submandibular region [96]. However, unlike sialoliths, which are typically aligned along the course of the salivary ducts, phleboliths more often show a multiple and irregular distribution that is not necessarily related to ductal anatomy [96,97]. The presence of multiple concentric radiopacities, especially when associated with soft-tissue swelling or a clinical history suggestive of a vascular malformation or hemangioma, is more consistent with phleboliths [93,96,97,98,99].

3.9. Laryngeal Cartilages

Calcifications of the triticeal and thyroid cartilages can frequently be visualized on OPG, and their identification is useful for the differential diagnosis of carotid calcifications [100]. In fact, triticeal cartilage calcifications are radiographically located at the level of the third and fourth cervical vertebrae (C3–C4), between the greater horn of the hyoid bone and the superior horn of the thyroid cartilage. Compared with carotid calcifications, however, they appear more oval, with a smooth, well-defined cortical border, and are centrally positioned within the lateral thyrohyoid ligament [101]. Calcifications of the thyroid cartilage are generally visible on OPG for only 2–3 mm, below the hyoid bone, medial to C4, at the lower margin of the radiograph [6], and may range from linear shadows to dense laminar calcifications [65].

4. Implications for Dental Practice

The findings summarized in this review reinforce the view that OPG should not be interpreted solely as an examination of the teeth and jaws. Owing to its wide field of view, an OPG may include anatomical regions in which vascular, sinonasal, skeletal, salivary, lymphatic, and other soft-tissue calcifications can be incidentally detected. For dental practitioners, the clinical relevance of these findings does not lie in establishing a definitive medical diagnosis but rather in recognizing radiographic patterns that may require documentation, clinical correlation, and, when appropriate, referral for specialist assessment. A first practical implication is the need for a systematic evaluation of the entire OPG [3,4,5,102]. In everyday dental practice, attention is often focused primarily on dentoalveolar structures, periodontal status, impacted teeth, periapical disease, implant planning, or temporomandibular joint morphology. However, the evidence reviewed here indicates that clinically meaningful extra-dental findings may be located outside the usual dental areas of interest, particularly in the laterocervical region, the maxillary sinuses, the mandibular angle, and the soft tissues of the floor of the mouth and neck [3,4,5,6,12,102]. Therefore, interpretation of OPG should include a structured assessment of both odontogenic and non-odontogenic regions, with particular attention to the number, morphology, distribution, laterality, and anatomical projection of radiopaque or radiolucent abnormalities [4,5,6,12].
Among the findings discussed, carotid artery calcifications are of particular importance because of their possible association with systemic vascular disease and cardiovascular risk factors [15]. When radiopacities compatible with carotid calcifications are identified near the C3–C4 level, inferior and posterior to the mandibular angle, the dentist should not infer the presence of carotid stenosis, nor should OPG be regarded as a substitute for dedicated vascular imaging. Nevertheless, such findings should be reported, particularly in older patients or in individuals with known cardiovascular risk factors, including hypertension, diabetes, smoking, dyslipidaemia, chronic kidney disease, previous radiotherapy, or a history of vascular events [16,17,18,19,50]. In these cases, appropriate communication with the patient and referral to the general practitioner, cardiologist, vascular specialist, or another suitable physician may enable targeted assessment with Doppler ultrasonography or other dedicated investigations when clinically indicated [3,50].
Findings involving the maxillary sinus represent another area in which dentists may play a clinically relevant role. OPG may reveal mucosal thickening, dome-shaped opacities, discontinuity of the sinus floor, antroliths, foreign bodies, or more extensive sinus opacification [53,54,56,59]. In dental practice, the main implication is the need to distinguish findings that may be related to dental disease from those more suggestive of rhinogenic, inflammatory, or neoplastic conditions [57,60,61,103]. When sinus alterations are adjacent to periapical lesions, periodontal defects, extraction sites, endodontic overfilling, implants, or oroantral communications, an odontogenic origin should be considered [55,58,62,63]. In such cases, Cone Beam Computed Tomography (CBCT) may be appropriate to evaluate the relationship between the maxillary posterior teeth, the sinus floor, and the extent of bony involvement [53,55,59]. Conversely, persistent unilateral opacification, irregular margins, bone destruction, soft-tissue extension, unexplained tooth displacement, paraesthesia, or symptoms not accounted for by dental disease should prompt referral to an otolaryngologist or oral and maxillofacial specialist, with further evaluation by Computed Tomography (CT) and/or Magnetic Resonance Imaging (MRI) [57,58,61].
Assessment of mandibular radiomorphometric indices also has practical implications. Evaluation of the mandibular cortical index and mandibular cortical width may help dentists identify patients, particularly peri- and postmenopausal women or older individuals, who may be at increased risk of low skeletal bone mineral density [64,65]. These indices should be regarded as opportunistic screening tools rather than diagnostic criteria for osteoporosis. Their clinical value is greatest when they are interpreted in conjunction with the patient’s age, sex, menopausal status, fracture history, medical history, and other clinical risk factors [66,67,68]. A markedly eroded mandibular cortex or reduced mandibular cortical width may justify referral for formal densitometric assessment, usually by Dual-energy X-ray Absorptiometry (DXA), but should not be used in isolation to diagnose osteoporosis or to initiate medical treatment [66,67,68,69].
Elongation or calcification of the styloid process and stylohyoid complex illustrates the importance of correlating radiographic findings with clinical symptoms [70,71,72]. An elongated styloid process is often an incidental and asymptomatic finding. Therefore, its detection on OPG does not automatically require treatment [72,73]. However, when elongation or calcification is associated with cervicofacial pain, dysphagia, odynophagia, otalgia, headache, tinnitus, trismus, or pain during head movement, Eagle syndrome may be considered in the differential diagnosis [74]. In such cases, the OPG may provide the first diagnostic clue, whereas CT or CBCT may be required to assess the morphology, length, angulation, and relationship of the stylohyoid complex to adjacent neurovascular structures before specialist management [73,74]. With regard to salivary gland calcifications, the practical role of OPG is mainly preliminary recognition. Sialoliths, particularly in the submandibular region, may appear as radiopaque masses along the expected course of the salivary ducts or glands [75,76,77,78,79,80,81]. Their detection should be integrated with clinical findings such as swelling, meal-related pain, recurrent sialadenitis, or reduced salivary flow [79,86]. When symptoms are present, or when localization is uncertain, additional imaging such as ultrasonography, occlusal radiography, CBCT, CT, or MR sialography may be required, depending on the suspected site and the differential diagnosis [76,79,82,83,84]. Distinguishing sialoliths from phleboliths is particularly important, as phleboliths may indicate an underlying venous malformation and should not be managed as simple salivary stones without further evaluation [96,97,98,99]. Tonsilloliths, calcified lymph nodes, phleboliths, and laryngeal cartilage calcifications further emphasize the importance of differential diagnosis. Tonsilloliths are generally benign and asymptomatic; however, their projection over the mandibular ramus and their possible ghost images may mimic other radiopacities [87,88,89]. Calcified lymph nodes, particularly when multiple, irregular, lobulated, or “cauliflower-like” in appearance, may represent sequelae of previous inflammatory or granulomatous disease, but may also require clinical correlation when unexplained or associated with systemic signs [90,91,92]. Phleboliths, especially when multiple and concentrically laminated, should raise suspicion for a vascular malformation when supported by clinical findings [93,94,95,96]. Triticeous and thyroid cartilage calcifications are relatively common anatomical or age-related findings and are particularly relevant because they may be mistaken for carotid calcifications. Recognition of their typical location, shape, and smooth, well-corticated margins can reduce false-positive interpretations and unnecessary referrals [100,101]. A central message for dental practice is therefore the need to balance vigilance with diagnostic caution [1,104]. OPG is a two-dimensional projection technique affected by magnification, distortion, anatomical superimposition, ghost images, and variability related to patient positioning; consequently, its sensitivity and specificity may vary, and both false-positive and false-negative interpretations may occur [1,104]. For this reason, non-odontogenic findings detected on OPG should generally be described as “compatible with”, “suggestive of”, or “requiring differential diagnosis”, rather than as definitive diagnoses [3,5,102]. The report should include the anatomical location, laterality, size when measurable, morphology, number of lesions, relationship to relevant landmarks, and the recommended clinical action [105,106]. This approach improves communication with both the patient and the receiving medical specialist [105]. The dentist’s responsibility is not to replace the physician, radiologist, otolaryngologist, vascular specialist, endocrinologist, or oral and maxillofacial surgeon, but to act as a sentinel healthcare professional. This role involves recognizing abnormalities, distinguishing likely benign variants from potentially relevant findings, avoiding overinterpretation, and initiating appropriate referral pathways. This is particularly important because many patients undergo OPG more frequently than other head and neck imaging examinations, and some systemic or extraoral conditions may first be suspected in the dental setting [3,5,13,102,106]. These implications also support the need for improved education and standardized reporting in dental radiology [105,107]. Undergraduate and postgraduate training should emphasize not only odontogenic pathology but also the recognition of common extra-dental calcifications and maxillary sinus abnormalities [106,107]. In clinical practice, checklists or structured reporting templates may help reduce missed findings and improve interpretive consistency [105]. However, OPG should not be prescribed solely for the purpose of screening for systemic diseases [2]. Its contribution should instead be understood as opportunistic: when an OPG is already justified for dental reasons, the entire image should be interpreted responsibly, and any relevant extra-dental findings should be managed according to their clinical significance.
Finally, future research should aim to clarify the diagnostic accuracy, interobserver reliability, referral thresholds, and patient outcomes associated with the detection of non-odontogenic findings on OPG. Prospective studies comparing OPG findings with Doppler ultrasonography, CT, CBCT, MRI, DXA, or clinical follow-up would help define which radiographic patterns have the highest predictive value and which findings warrant specialist referral. Until stronger evidence is available, the most appropriate approach remains cautious, systematic, and clinically integrated interpretation of OPG.

5. Conclusions

OPG offers dentists an opportunity to observe not only odontogenic disease but also findings that may reflect conditions beyond the dentoalveolar region. Its clinical value therefore depends on the dentist’s ability to interpret the image as a whole, rather than as a strictly dental examination. The dentist should be regarded as a first-line observer within a broader diagnostic pathway. Recognition of non-odontogenic findings, appropriate documentation, and timely communication with patients and medical specialists may contribute to earlier identification of clinically relevant conditions. At the same time, this role must be exercised with diagnostic caution. OPG should guide suspicion and support referral when needed, but it should not be used as a stand-alone diagnostic tool for extraoral or systemic disease. Strengthening radiological training and promoting systematic whole-image assessment may enhance the contribution of dental practice to interdisciplinary patient care.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/app16136344/s1, Supplementary S1. Search strategies.

Author Contributions

Conceptualization, D.D.F., M.P. and N.M.; methodology, D.D.F. and M.P.; validation, D.D.F., M.P. and N.M.; formal analysis, N.M. and D.D.F.; investigation, D.D.F., N.M., M.R. and F.S.; resources, D.D.F. and N.M.; data curation, D.D.F., M.K. and M.P.; writing—original draft preparation, D.D.F., N.M. and M.P.; writing—review and editing, D.D.F. and M.P.; visualization, M.R., F.S., M.P. and M.K.; supervision, D.D.F. and M.P. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Data Availability Statement

No new datasets were generated or analyzed during the current study. The data supporting the findings of this review are derived from previously published articles, which are cited in the reference list. The archival radiographic images included in this article were anonymized and are not publicly available due to privacy and ethical restrictions.

Acknowledgments

The authors gratefully acknowledge D. Boscia for providing the radiographic material used in this study.

Conflicts of Interest

The authors declare no conflicts of interest.

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