Research diagnostic criteria for temporomandibular disorders (RDC/TMD): development of image analysis criteria and examiner reliability for image analysis

Abstract

Objective: As part of the Multisite Research Diagnostic Criteria For Temporomandibular Disorders (RDC/TMD) Validation Project, comprehensive temporomandibular joint diagnostic criteria were developed for image analysis using panoramic radiography, magnetic resonance imaging (MRI), and computerized tomography (CT).

Study design: Interexaminer reliability was estimated using the kappa (kappa) statistic, and agreement between rater pairs was characterized by overall, positive, and negative percent agreement. Computerized tomography was the reference standard for assessing validity of other imaging modalities for detecting osteoarthritis (OA).

Results: For the radiologic diagnosis of OA, reliability of the 3 examiners was poor for panoramic radiography (kappa = 0.16), fair for MRI (kappa = 0.46), and close to the threshold for excellent for CT (kappa = 0.71). Using MRI, reliability was excellent for diagnosing disc displacements (DD) with reduction (kappa = 0.78) and for DD without reduction (kappa = 0.94) and good for effusion (kappa = 0.64). Overall percent agreement for pairwise ratings was >or=82% for all conditions. Positive percent agreement for diagnosing OA was 19% for panoramic radiography, 59% for MRI, and 84% for CT. Using MRI, positive percent agreement for diagnoses of any DD was 95% and of effusion was 81%. Negative percent agreement was >or=88% for all conditions. Compared with CT, panoramic radiography and MRI had poor and marginal sensitivity, respectively, but excellent specificity in detecting OA.

Conclusion: Comprehensive image analysis criteria for the RDC/TMD Validation Project were developed, which can reliably be used for assessing OA using CT and for disc position and effusion using MRI.

Figure 1

Sagittal CT views of condyles representing examples of nonosteoarthritic or indeterminate osseous changes observed. A-B. Rounded condylar head, and well-defined cortical margin. C. Rounded condylar head, and well-defined noncortical margin. D-E. Indeterminate for OA: slight flattening of anterior slope and well-defined cortical margin. F. Indeterminate for OA: flattening of anterior slope and a pointed anterior tip that is not sclerosed, well-defined cortical margin, fossa is shallow. G. Well-defined cortical margin has a notch on the superior part, a deviation in form, fossa is shallow. H. Narrowed appearance of the condylar head near medial part, close position of the cortical plates gives the impression of sclerosis, a nonosteoarthritic condyle,

Figure 2

Sagittal CT views of condyles representing examples of osseous changes observed, and corresponding osteoarthritis (OA) diagnoses. A. Indeterminate for OA: subcortical sclerosis without any flattening, without erosion. B. OA: subcortical sclerosis, osteophytic growth on the anterior part of the condyle. C. OA: subcortical sclerosis, flattened posterior slope of the eminence, osteophytic growth on the anterior part of the condyle, limited joint space superiorly. D. OA: flattened superior margin, osteophytic growth at the anterior, fossa is shallow. E. OA: flattened posterior slope of the eminence, condylar margin is eroded and lacks corticated border, osteophytic growth. F. OA: flattened superior margin, decreased condylar height, margin is eroded and lacks corticated border, osteophytic growth, outline of the fossa is irregular. G. OA: a bony cavity below the articular surface margin (i.e., subcortical cyst), osteophytic growth, posterior slope of the eminence is sclerosed. H. OA: generalized sclerosis, surface erosion, osteophytic growth, sclerosed fossa.

Figure 3

Axially corrected coronal CT views of condyles representing examples of osseous changes observed, and corresponding osteoarthritis (OA) diagnoses. A-B. Nonosteoarthritic condyles, rounded condylar head, and well-defined cortical margin. C. Nonosteoarthritic condyle, flattened superior margin, and well-defined cortical margin. D. Nonosteoarthritic condyle, flattened lateral slope, and well-defined cortical margin. E. Indeterminate for OA: rounded condylar head and subcortical sclerosis. F. Indeterminate for OA: subcortical sclerosis. G. OA: subcortical sclerosis, surface erosion. H-I. OA: surface erosion. J. OA: generalized sclerosis, and subcortical cysts. K. Nonosteoarthritic condyle, well-defined corticated margin, bifid appearance, deviation in form. L. Nonosteoarthritic condyle, subcortical sclerosis in nonarticulating surface, bifid appearance, deviation in form.

Figure 4

Sagittal proton density MR views representing examples of changes in the soft tissue components of the TMJ observed, and corresponding disc diagnoses. A-B. Normal disc location: normal biconcave disc shape, posterior band is at 11:30-12:30 position, intermediate zone is in contact with the condylar head. C. Normal disc location: thinning of the disc, posterior band is at 11:30-12:30 position, intermediate zone is in contact with the condylar head. D-E. Indeterminate for disc location: normal biconcave disc shape, posterior band is at 11:30-12:30 position, intermediate zone is not in contact with the condylar head. F. Anteriorly displaced disc: normal biconcave disc shape, posterior band is at <11:30 position, intermediate zone is not in contact with the condylar head. G. Anteriorly displaced disc: intermediate zone is not visible. H Anteriorly displaced disc: thickened disc.

Figure 5

Sagittal proton density MR views representing examples of changes in the soft tissue components of the TMJ observed, and corresponding disc diagnoses. Images on the upper panel are in closed-mouth position. Images in the lower panel are in open mouth position. A. Anteriorly displaced disc: thickened disc. B. Anteriorly displaced disc: deformed disc shape, posterior band is thickened, generalized sclerosis of the condylar head. C-D. Anteriorly displaced disc: deformed disc shape. E. Reduction of the disc position (while the mouth is open): normal disc shape, intermediate zone is in contact with the condylar head. F. Reduction of the disc position (while the mouth is open): posterior band is thickened, intermediate zone is in contact with the condylar head. G. Non-reduction of the disc position (while the mouth is open): intermediate zone is not detectable. H. Non-reduction of the disc position (while the mouth is open): intermediate zone is detectable.

Figure 6

Sagittal T2 MR views representing examples of changes in the soft tissue components of the TMJ observed, and presence of effusion. A-B. Anteriorly displaced disc, and effusion in the superior joint space. C-D. Anteriorly displaced disc, and effusion in both the joint spaces.

Figure 7

Axially corrected coronal MR views in the closed-mouth position representing examples of changes in the soft tissue components of the TMJ observed. A-C. Centrally located disc. Image C shows bifid condyle. D-F. Disc is laterally displaced. G-H. Medial displacement of the disc.