A panoramic radiograph shows a radiopaque mass near the angle of the mandible. What is the most important first differential diagnosis?

Correct answer: C. Carotid artery calcification

• A. A tonsillolith would appear in the tonsillar fossa area, not at the angle of the mandible.
• B. Lymph node calcification can appear in this region and is a valid differential.
• C. Correct. Carotid artery calcification near the angle of the mandible is the most clinically significant finding to identify on panoramic radiograph because it indicates atherosclerosis and risk for stroke. A vertical, tubular or heterogeneous calcification near the C3-C4 cervical level on pano suggests carotid calcification.
• D. A sialolith (salivary stone) would be seen in association with a salivary gland duct, not at the angle of the mandible.