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J Am Dent Assoc, Vol 133, No 4, 442-451.
© 2002 American Dental Association
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CLINICAL PRACTICE

Comparing methods for diagnosing temporomandibular joint disk displacement without reduction



RÜDIGER EMSHOFF, M.D., D.M.D., IRIS BRANDLMAIER, M.D., STEFAN BERTRAM, M.D., D.M.D. and ANSGAR RUDISCH, M.D.


   ABSTRACT
TOP
 ABSTRACT
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Background. Research is needed to assess the validity of the Clinical Diagnostic Criteria for Temporomandibular Disorders, or CDC/TMD. The authors conducted a prospective, double-blind study to determine whether applying the specific CDC/TMD diagnosis of TMJ internal derangement, or ID, type III would demonstrate good agreement with diagnoses obtained by MRI.

Methods. The study comprised 138 TMJs in 69 subjects who had a clinical diagnosis of unilateral TMJ ID type III (disk displacement without reduction). The authors obtained bilateral sagittal and coronal MRIs to establish the corresponding diagnosis of disk-condyle relationship.

Results. For the CDC/TMD interpretations, the positive predictive value of ID type III for disk displacement without reduction was 86 percent, and for the presence of an ID it was 91 percent. The overall diagnostic agreement for ID type III was 78.3 percent with a corresponding {kappa} value of 0.57. Most of the disagreement was due to false-positive interpretations of an absence of ID.

Conclusions. The results suggest that using CDC/TMD for ID type III is predictive for the presence of an ID but is not sufficiently reliable for determining disk displacement without reduction. Parameters other than the functional disk-condyle relationship may need to be addressed to account for the biological plausibility of this entity.

Clinical Implications. A clinical TMJ-related diagnosis of ID type III may need to be supplemented by evidence from an MRI to determine the functional disk-condyle relationship. Investigation of longitudinal evidence, including risk factors, history and response to treatment, appears to be warranted.

The measurable and reproducible set of Clinical Diagnostic Criteria for Temporomandibular Disorders, or CDC/TMD, for the most common forms of TMD was published in 1992 to provide a standardized definition of diagnostic sub-goups of patients with orofacial pain and TMDs.1 Each criterion refers to a particular examination and interview item, and each item is accompanied by specifications on how to perform the diagnostic procedure.2

A clinical temporomandibular joint–related diagnosis of internal derangement type III may need to be supplemented by evidence from a magnetic resonance image.

CDC/TMD was developed in an attempt to form a common set of working criteria for classifying subjects in TMD epidemiology and treatment studies. It classifies the most common forms of TMD into the main diagnostic subgroups of masticatory muscle disorder; temporomandibular joint, or TMJ, internal derangement, or ID; and TMJ degenerative joint disease. To verify that these disorders and diseases represent distinct entities, data supporting decisive differences in the areas of pathogenesis, treatment and prognosis are essential.3 Validating the masticatory muscle disorder subgroup may be difficult because of the lack of available definitive diagnostic procedures or of "biological gold standards" that may define some pathological changes.4–6 TMJ imaging techniques, on the other hand, can be used to validate the diagnostic criteria for TMJ ID and TMJ degenerative joint disease. Magnetic resonance imaging, or MRI, is the most accurate imaging modality for identifying TMJ disk positions and may be regarded as the "gold standard" for disk position identification purposes.7 A study of observer variation when the classification system proposed by Tasaki and colleagues8 is used has shown a low level of intraobserver and interobserver variability.9

We conducted this prospective, double-blind study to determine whether applying the specific CDC/TMD diagnosis of TMJ ID type III would demonstrate good agreement with diagnoses obtained by MRI.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Subjects. The study group consisted of 69 consecutively seen patients referred from medical practitioners and dentists in the community to the Orofacial Pain and Temporomandibular Disorder Clinic in the Department of Oral and Maxillofacial Surgery at the University of Innsbruck, Austria. This clinic is the primary referral center for TMD at the university, and it offers both conservative and surgical treatments. There were 59 female patients and 10 male patients, who had a mean age of 35.9 years (range, 12–79 years). We informed the subjects about the study procedure and obtained their written informed consent.

Criteria for inclusion in the study were unilateral signs and symptoms characteristic of a TMJ-related diagnosis of ID type III (disk displacement without reduction), absence of a contralateral diagnosis of ID type I (disk displacement with reduction) or ID type II (disk displacement with reduction and episodic catching), no concomitant TMD diagnosis of degenerative joint disease, absence of signs and symptoms that characterized a diagnosis of myalgia, no history of trauma and absence of collagen vascular disease.

To determine the reliability of the clinical diagnosis of TMJ ID type III compared with MRI diagnosis, we clinically evaluated the subjects and then had them undergo MRI investigation. One clinician (R.E.) performed the clinical evaluation of each subject.

The clinical assessment consisted of a standardized evaluation of mandibular range of motion, joint pain and auscultation of joint sounds. Mandibular range of motion was evaluated for maximum opening and lateral movements; maximum opening was measured from central maxillary incisor to the opposing mandibular incisor, using a millimeter ruler. The clinician measured lateral movements relative to the maxillary midline with the teeth slightly separated. TMJ pain was identified during palpation, mandibular range of motion or assisted mandibular opening. The TMJs were auscultated with a stethoscope, with the subject performing three openings and three lateral and protrusive movements. The joint sounds were described as single and reciprocal clicks.2 We made clinical TMD diagnoses based on the CDC/TMD (Table 1Go).1


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  		TABLE 1 CLINICAL DECISION CRITERIA FOR TMD* DIAGNOSTIC CATEGORIES.{dagger}

 
The TMJ ID type III subgroup was defined by the CDC/TMD1 as subjects having a history of sudden reduction in mandibular opening, an unassisted mandibular opening less than 35 mm and an assisted mandibular opening increased by 3 mm or less than an unassisted opening. In subjects with a history of clicking, click disappearance and sudden decreased opening needed to coincide. If there was an absence of clinical inclusion criteria defining one of the ID subgroups, we accepted clinical evidence of absence of disk displacement.

The single clinician (R.E.) performed the clinical evaluations and followed a structured protocol.2,10,11 The intraobserver reliability was satisfactory ({kappa} > 0.75) to excellent ({kappa} = 1.00) for all of the CDC/TMD items; the majority had a {kappa} value of 1.00.

MRI. Using MRI, a single radiologist (A.G.) made the diagnoses of the disk-condyle relationship. We carried out MRI with a 1.5 tesla MRI scanner and a dedicated circular-polarized transmit-and-receive TMJ coil. The data were collected on a 252 x 256 dots-per-inch matrix with a field of view of 145 mm, giving a pixel size of 0.60 x 0.57 mm.

With the subject in a supine position, we obtained 15 coronal slices and eight parasagittal slices of each TMJ using a turbo-spin-echo–proton-density sequence (repetition time, 2,800 milliseconds; echo time, 15 ms) with thin 3-mm slices. MRIs were corrected to the horizontal angulation of the long axis of the condyle. We made sequential bilateral images with the subjects’ mouths closed and at the respective maximum mouth-opening positions.

The radiologist (A.R.) assessed the MRIs using established criteria for normal disk position vs. disk displacement. We defined normal disk position as the posterior band of the disk’s being located at the superior, or 12 o’clock, position relative to the condyle, whereas we defined disk displacement as the posterior band of the disk’s being in an anterior, anteromedial, anterolateral, medial or lateral position relative to the superior part of the condyle. We categorized diagnosis of the disk-condyle relationship as normal (absence of ID) (Figure 1Go), disk displacement with reduction (Figure 2Go, page 446) and disk displacement without reduction (Figure 3Go, page 447). We based our categorizations on the finding of a closed–mouth-related diagnosis of absence or presence of disk displacement associated with or without an open–mouth-related interposition of the disk between the condyle and the articular eminence.8



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  		Figure 1. Magnetic resonance images, or MRIs, of a patient with a right-side–related clinical diagnosis of temporomandibular joint, or TMJ, internal derangement, or ID, type III, with absence of ID. A. Sagittal closed-mouth–related MRI shows posterior band of the disk (arrows) superior to condyle. B. Sagittal open-mouth–related MRI shows disk superior to condyle (arrows).

 


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  		Figure 2. Magnetic resonance images, or MRIs, in a patient with a right-side–related clinical diagnosis of temporomandibular joint, or TMJ, internal derangement type III, with presence of disk displacement with reduction. A. Sagittal closed-mouth–related MRI shows posterior band of the disk (arrows) anterior to condyle. B. Coronal closed-mouth–related MRI shows disk anterolateral to condyle (arrows). C. Sagittal open-mouth–related MRI shows posterior band of the disk (arrows) superior to condyle. D. Coronal open-mouth–related MRI shows disk superior to condyle (arrows).

 


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  		Figure 3. Magnetic resonance images, or MRIs, in a patient with a left–side-related clinical diagnosis of temporomandibular joint, or TMJ, internal derangement type III, with presence of anterior disk displacement without reduction. A. Sagittal closed-mouth–related MRI shows disk (arrows) anterior to condyle. B. Coronal closed-mouth–related MRI showing anterior disk displacement (arrows). C. Sagittal open-mouth–related MRI shows disk (arrows) anterior to condyle. D. Coronal open-mouth–related MRI shows disk anterior to condyle (arrows).

 
Data analysis. We evaluated the statistical significance of the diagnostic percentage agreement between the clinical findings and MRI diagnoses using the {kappa} statistical test and determined the predictive value of the CDC/TMD for ID type III. The resulting {kappa} values determined the level of agreement corrected by chance. We used a specialized software package (SPSS, Version 7.5.2G, SPSS Inc., Chicago) to conduct all of the statistical analyses.


   RESULTS
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
The MRI diagnoses made by the radiologist are shown in Table 2Go (page 448). In the 69 TMJs with a clinical diagnosis of absence of ID, we made an MRI diagnosis of absence of ID in 25 (36.2 percent), while we found that 24 (34.8 percent) had a diagnosis of disk displacement with reduction and 20 (29.0 percent) had a diagnosis of disk displacement without reduction. In the 69 TMJs with a clinical diagnosis of ID type III, we made an MRI diagnosis of TMJ ID in 63 (91.3 percent); four (5.8 percent) had a diagnosis of disk displacement with reduction, and 59 (85.5 percent) had a diagnosis of disk displacement without reduction.


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  		TABLE 2 MRI* DIAGNOSIS OF TYPE OF INTERNAL DERANGEMENT IN SUBJECTS WITH A UNILATERAL CDC/TMD{dagger}DIAGNOSIS OF DISK DISPLACEMENT WITHOUT REDUCTION.{ddagger}

 
We found that in 84 TMJs, MRI validated the disk-condyle relationship. Among TMJs with an MRI diagnosis of an absence of ID and disk displacement without reduction, there were 25 true-positive and six false-negative findings for the absence of ID group, and 59 true-positive and 20 false-negative findings for the ID type III group (Table 3Go, page 448). The sensitivity for detection of absence of ID was 81 percent and the specificity was 59 percent (Table 4Go, page 449). For detection of disk displacement without reduction, the sensitivity was 75 percent and the specificity was 83 percent.


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  		TABLE 3 CDC/TMD* DIAGNOSES OF INTERNAL DERANGEMENT

 

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  		TABLE 4 PROSPECTIVE CDC/TMD* DIAGNOSIS OF INTERNAL DERANGEMENT TYPE.{dagger}

 
Among TMJs with a CDC/TMD diagnosis of absence of ID, MRI showed that 25 had an absence of ID (positive predictive value, or PPV, 36 percent) and 44 had a presence of ID (negative predictive value, or NPV, 91 percent) (Table 4Go). Of the TMJs with a CDC/TMD diagnosis of ID type III, 59 had disk displacement without reduction (PPV, 86 percent) and 10 had an absence of ID type III (NPV, 71 percent). The presence of an ID was diagnosed correctly by CDC/TMD in 63 of the 69 TMJs with an ID type III (PPV of 91 percent).

Comparing the agreement of the clinician relative to the MRI diagnoses, the {kappa} values for ID and ID type III rated 0.28 and 0.57, respectively, indicating poor agreement with the MRI diagnosis of ID and fair agreement with that of disk displacement without reduction (Table 5Go, page 449).


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  		TABLE 5 DIAGNOSTIC AGREEMENT AND RELIABILITY BETWEEN CLINICIAN AND MRI.*{dagger}

 

   DISCUSSION
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
In this study, we used a set of specified operational criteria to classify patients who have TMD. This approach to clinical measurement produced a high correlation between the prospective CDC/TMD diagnosis of ID type III and the findings at MRI, with a PPV of 86 percent for disk displacement without reduction and 91 percent for ID.

To our knowledge, no previous study has investigated systematically the diagnostic value of CDC/TMD for assessing MRI diagnoses of ID. Various TMD findings have been reported, but their predictive values in specified subject-related CDC/TMD subgroups are not known. Barclay and colleagues12 described PPV, NPV and accuracy of specific clinical diagnoses in the detection of ID in a study. That work used the Research Diagnostic Criteria for TMD, or RDC/TMD, and was performed with a study group of 40 consecutive patients clinically diagnosed with disk displacement with reduction in at least one TMJ. It had a PPV of 56 percent for disk displacement with reduction, a PPV of 92 percent for ID and a preponderance of false-negative errors, especially for asymptomatic TMJs. Comparison of the reported values with those of our current study, however, may not be possible, as Barclay and colleagues’ study was performed to assess the validity of the RDC/TMD subgroup of disk displacement with reduction. To classify the use of CDC/TMD for the assessment of MRI diagnoses of ID with appropriately tested validity, further studies comparing MRI data with those of specific diagnostic subgroups offering a high degree of intra- and interobserver reliability may be warranted.13

Several authors have investigated the accuracy of clinical diagnosis for TMJ ID using arthrography and MRI as a gold standard. The reported percentage agreement ranged from 59 percent to 90 percent, depending on the diagnostic criteria used in the respective studies.14–22 Some authors investigated single items of mandibular range of motion, TMJ sounds, dental occlusion, TMJ pain and masticatory muscle pain in their predictive value of TMJ ID.14–19 Other authors used strict inclusion criteria for one diagnosis, but failed to describe essential characteristics that distinguish one diagnosis from another.20–22 This ambiguity between essential and nonessential features of the various TMD subgroups may have resulted in low reliabilities concerning the classification of patient groups in these studies. With regard to the diagnostic system applied in our current study, the overall intra- and interobserver reliability has not been tested yet; however, the use of strict inclusion and exclusion criteria may have defined homogeneous clinical subgroups of patients who have TMDs.

Based on our study, clinical classification revealed an unacceptable agreement between the clinician in his diagnoses of ID type III and the radiologist in his corresponding MRI diagnoses of disk displacement without reduction. This finding may reflect the difficulty in separating the absence of ID group from the ID type I group, as the absence of ID group was not defined as a wellness gold standard without signs and symptoms or history of TMD. The only difference between these diagnostic groups in specified diagnostic criteria was the absence of clicking during vertical mandibular range of motion or lateral or protrusive excursions (Table 1Go). Further, it confirms the results of previous studies that suggest disk displacement to be prevalent in asymptomatic TMJs in up to 21 percent to 33 percent.8.23 With a percentage agreement of 78.3 percent for ID type III, the plausibility of disk displacement may be questioned. As the decision criteria may be highly specific for a "locked joint," other parameters may have to be addressed to account for the biological plausibility of these enities.24,25

Several studies have focused on the importance of disk displacement as the underlying mechanism in the etiology of TMJ-related pain and dysfunction.8,23,26,27 With the observation that arthroscopic lysis and lavage, as well as arthrocentesis and hydraulic distension of the upper joint space, are associated significantly with a reduction in TMJ-related pain and an increase in mandibular range of motion, the diagnostic and therapeutic significance of TMJ disk displacement has been questioned by several authors.28–31 Arthroscopic studies have confirmed that inflammatory processes of the synovium, capsule or retrodiskal tissues are the underlying mechanisms for the occurrence of TMJ-related pain.32 Since any impediment in the upper or lower joint space may result in a restriction of range of mandibular motion, alterations in the constituents of the synovial fluid affecting the lubrication of the TMJ,33 as well as reversible adhesions of the disk to the glenoid fossa caused by vacuum effects or changes in synovial fluid viscosity have been proposed as etiologic processes in the development of restricted gliding movements of the mandibular condyle over the articular eminence.34 Further research, however, may be warranted to assess underlying variables as possible initiating, predisposing or perpetuating factors in the etiology of certain TMJ-related pain and dysfunction conditions.

In our current study, we used the gold standard MRI criterion (the 12 o’clock position) to define normal disk position,35,36 and we determined the PPV and NPV of CDC/TMD parameters for predicting the condition of the TMJ established by this criterion. Disk displacement according to this criterion, however, has been observed in normal, asymptomatic volunteers, raising the question of what should be considered an abnormal disk position.8,23,37–39 In terms of disease classification, a more accurate diagnostic operational criterion to define TMJ disk displacement may be needed. One that is related closely to the clinical signs and symptoms of the disorder may be needed to avoid over- and undertreatment and to obtain a more cost-effective outcome.

The findings of our study raise the question of whether the use of clinical diagnostic criteria in clinical settings may need to be supplemented by imaging techniques to distinguish among subtypes of TMD. Arthrographic and MRI evaluation of the soft-tissue components of the TMJ may not always be available. Arthrography is an invasive technique, and MRI use may be limited by cost; thus, most of the evaluative approaches for patients who have TMD are symptom-based. Therefore, several studies have been conducted to determine the accuracy of clinical and adjunctive diagnostic tests; the accuracy rates obtained for TMJ ID have ranged from 43 percent to 90 percent.18,20,22,24,40–42

Questions also have arisen as to which diagnostic approach should be selected and how the test results should be interpreted. The choice of criterion may depend on the relative values the decision maker places on making false-positive and false-negative diagnoses, as well as the changes in treatment benefits and risks.43–45 It may be argued that since only a low percentage of the general population seeks treatment for symptoms of disk displacement and because asymptomatic patients who are incorrectly diagnosed with disk displacement may incur unnecessary and potentially damaging treatment, lower sensitivity levels for an increase in specificity may be used for this disorder so that false-positive diagnoses can be avoided.46–48

From a methodological point of view, etiology, prognostic statements and implications for treatment are considered to be the main indicators for the utility of a diagnostic system.49 While there is a lack of knowledge regarding etiology, Kurita and colleagues50 have provided data for prognosis. In their prospective cohort study of the course of untreated symptomatic TMJ disk displacement without reduction, they followed 40 patients for a period of 2.5 years. The results indicated that approximately 40 percent of patients were free of symptoms within 2.5 years, one-third had improved, and one-quarter continued to be symptomatic. The authors concluded that this knowledge would be valuable for treatment planning and that the use of Wilkes’ classification system,51,52 which was based on both clinical and MRI observations, may be the best predictor of outcome.

As the CDC/TMD system is oriented mainly toward epidemiologic applications, the criteria were established to not require imaging. Instead, they were based more on a description of observable findings that appear to cluster together than on underlying etiologic mechanisms.

Further studies may be warranted to verify that CDC/TMD-related disorders truly represent distinct natural entities showing decisive differences in terms of prognosis and treatment outcome.3


   CONCLUSION
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
We conducted this prospective, double-blind study to determine whether applying the specific CDC/TMD diagnosis of TMJ ID type III would demonstrate good agreement with diagnoses obtained by MRI.

Our study of the CDC/TMD system has failed to prove that the subgroup ID type III is a valuable predictor of MRI-related diagnosis of TMJ disk displacement without reduction. In the absence of biological gold standards or definitive diagnostic procedures to classify patients who have TMD in a way that is consistent with the CDC/TMD system, validation of diagnostic entities within the CDC/TMD system would involve the investigation of cross-sectional and longitudinal evidence to determine the homogenity of the classified groups, including risk factors, history and response to treatment.53


   FOOTNOTES
 

Dr. Emshoff is an associate professor, Department of Oral and Maxillofacial Surgery, Höhenstraße 5, 6020 Innsbruck, Austria, e-mail "Ruediger_Emshoff{at}hotmail.com". Address reprint requests to Dr. Emshoff.


Dr. Brandlmaier is a research fellow, Department of Oral and Maxillofacial Surgery, University of Innsbruck, Austria.


Dr. Bertram is a consultant, Department of Oral and Maxillofacial Surgery, University of Innsbruck, Austria.


Dr. Rudisch is a consultant, Department of Magnetic Resonance Imaging and Department of Radiology, University of Innsbruck, Austria.


   REFERENCES
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

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