Dr. Berger,

To identify myself, I am a dentist who, for the past 35 years has had a practice devoted to the non-surgical management of temporomandibular disorders. I find your question very interesting and I have to say that to respond adequately will require some discussion. I would prefer to interact with you via email, rather than trying to do so on this site. My email address is [email protected]. I believe that I can provide you with some thoughtful responses to your question.

But before we begin that communication, I have a question for you that will help me respond: You state that you think that the use/overuse of the term, temporomandibular disorders, brings more problems than benefits. My question is "more problems for whom?". Do you see the use of that term being more of a problem for academics, for clinicians, or for patients? There would be a different response to each of these.

I hope to hear from you and will enjoy a conversation on your views related to the whole subject of temporomandibular disorders ("TMJ").

Samuel J. Higdon, DDS

Portland, Oregon, USA

Dr. Berger,

If I went to an orthopedist with pain in my knee, initially it would be referred to as a "knee disorder" – very non-specific. But with a careful evaluation and perhaps some imaging, a biologically-specific diagnosis could be determined and appropriate terminology used to define it. Is that any different than the current use of TMD as a general term, until a biologically-specific diagnosis can be made? I agree with you that, in the literature, the use of TMD is too loosely used. I have often had the same question that you do – what did the author mean by the use of TMD.

The reality is that we still don't have an adequate classification system for defining these conditions in specific terms. The Research Diagnostic Criteria may be useful for researchers but it not very useful for the average dental clinician. In reality, TMDs exist as a spectrum, from relatively simple conditions to quite complex conditions. And there are no clear lines of demarcation between them. In addition, because there are two joints, you can conceivably have one diagnosis on the right and a different one on the left. If you are interested, I can send you a diagnostic classification scheme that I believe would be helpful for the clinician in making these distinctions. My email address is [email protected].

So in ones sense I understand your frustration with the use of the term, TMD. But until there is wider understanding within our profession regarding the actual biological nature of these conditions, I really can't imagine that there will be a more appropriate use of terminology relating to these conditions.

Samuel J. Higdon, DDS

Dear Dr. Higdon,

Thank you very much for your comment and interesting thoughts on the subject.

First of all I would like to respond to your question – for whom the term TMD brings most problems? In my opinion the problem affects all mentioned groups – patients, clinicians and academics. Researchers use the term TMD very often in places where generalization is needed – title, abstract, conclusions. However, in the texts it is usually specified in the material and methods section what form/s of TMD was/were investigated (specific diagnoses e.g. according to RDC/TMD or DC/TMD). Therefore readers know what autor/s meant while referring to term TMD.

In my opinion, the use of the term TMD may be justified while multiple diagnoses are included into the study. Then title using the term TMD clearly shows that the study is about the group of disorders/clinical problems. Contrarily, when only one specific diagnosis or one clinical problem (e.g. pain) is included into the study then one should avoid using general term TMD and use more specific description. Unfortunately this is not common practice and in this terms may bring confusion, especially when read by person not well oriented in the topic. I think that problems of clinicians and patients are secondary to problem of academics who give bad example with the ease of use the term TMD while having so different meanings in mind (TMD as a group o clinical problems related to TMJs and masticatory muscles, TMD as a chronic pain condition, TMD as a mainly TMJ problem etc.).

It is interesting that you compare the term TMD to terms like „knee disorder” – non-specified problem of a specific anatomical site. Such terms ale very useful in clinical practice especially in diagnostic process. However, in feel that TMD sounds more like „femorotibial disorder” instead of „knee disorder”. I also fell like the term TMD is about to show complexity of the TMJ and muscle problems and refer to interactions between specific TMD diagnoses. But isn’t it the same with the knee or every other joint?? Aren’t muscles affected by joint problems? Therefore, I think that we should refer to TMJ problems the same way as orthopedist refer to knee problems, calling them knee disorders instead of „femorotibial dysfunction”.

I honestly think that life without the term TMD is possible and would save us from tons of confusion and effort trying to understand what somebody means saying TMD.

I personally try to refer directly to specific clinical problem – orofacial pain, headache, limited mouth opening, sounds in the TMJs or anatomically oriented problems – masticatory muscles problem, neck muscles problem, TMJ problem. For example, it is much better for me when somebody tells me „I have patient with headache and masticatory muscle problem” than „I have patient with TMD”. The first sentence is very informative, while the second seems like waste of time.

In conclusion, I think that the example should come from academics and that is why I posted this question here on RG. If we would start using more clinically understandable terms more often then clinicians knowledge about problems related to TMJ and muscles of mastication will also increase, from which patients will greatly benefit.

Of course I would like to hear some voices of disagreement with my opinion and I will be happy to further discuss on this topic.

We seem to be in general agreement re. the generic use of the term, TMD. But in the absence of a broad understanding, not just among academics, but more particularly, among clinicians, of the broad spectrum of disorders that are included under the rubric of "TMD" (or even less favorably, "TMJ"), I believe that there is a use for the term TMD. It would be helpful, I believe, if it was more broadly understood that the term TMD, in fact, does not represent a specific disorder but is a broad generic term used to designate a spectrum of disorders of the masticatory musculoskeletal system. But that is not a problem that you or I are going to solve. So I propose that, under current circumstances, there is a useful place for the term, TMD, but that it should be properly used.

I would like to propose another subject for your consideration. In nearly all of the dental literature that discusses Temporomandibular Disorders, I believe you will find that these conditions are largely defined by the presenting signs and symptoms, principally pain. My challenge to you is to consider this proposition — that the symptoms are not the problem, they are an expression of the problem. The problem is dysfunction. When we understand the functional anatomy and pathophysiology of the masticatory system sufficiently well, we can understand and address the dysfunction that leads to the symptoms. I would also propose to you that definitive treatment of these conditions requires that the pathophysiology be directly addressed, not just the symptoms, with the goal of restoring, to the degree possible, functional physiologic homeostasis to the system. This is true rehabilitation.