What's in a Name?

by Milton & Renée Glass

Founders and Presidents, JJAMD Foundation

What’s-In-A Name?

If a rose is a rose is a rose, then why is TMJ called TMD?

What's in a name? "That which we call a rose by any name would smell as sweet." (Wm. Shakespeare) While the olfactory organs may be satisfied with any name, as long as the smell is sweet, the same may not hold true for TMJ patients -- that devastated population for whom the name of their disorder, "TMJ," may be the last hope for humane recognition of their pain and dysfunction by the medical profession, health insurers, family members, friends, co-workers -- even society as a whole.

Let's Start at the Beginning

Hippocrates Time:

This health disorder was recorded as early as the time of Hippocrates, the Greek doctor for whom the "Hippocratic Oath" was named. To this day, and for the millennia, physicians swear an oath to "...do no harm."

The 1920's:

The acronym "TMJ" is almost as old as the modern "popularization" of the disorder itself. For a time it was known as "Costen's Syndrome," after the otolaryngologist, Dr. James Costen, who first noted the apparent relationship between occlusion and Temporomandibular Joint involvement. It was later described as Temporomandibular Joint Disorder (Dysfunction or Syndrome), or "TMJ" -- the same acronym being given to the disorder as to the anatomical joint itself. The term was used to describe a disorder affecting the joint, the related musculature that makes the joint work, and the associated structures, ligaments and tissue surrounding these joints.

1982:

We establish the JJAMD Foundation to increase awareness and knowledge of the Temporomandibular Joints, their structure, function, relationship and importance to the rest of the body, and to make "Jaw Joints" a household word.

Simultaneous to the formation of the JJAMD

Foundation, the American Dental Association (ADA) chooses to drop the "Joint" from "Temporomandibular Joint Disorder," and the "J" from the acronym "TMJ." The term "Temporomandibular Disorders" and "TMD" is adopted as the Dental profession's new household word.

In addition, a variety of other new names and acronyms continue to surface. We believe this name changing further clouded and confused the general public and other health care professionals as to what health disorder they were dealing with. We believe we should go back to the term "TMJ," the historical name, to help alleviate confusion surrounding an already baffling disorder. These new names and acronyms have not helped anyone resolve the controversy surrounding the etiology, diagnosis and treatment of this disorder. Nor do we believe it has helped the image of Dentistry.

1994:

Most, but by no means all, of the Dental profession now refer to this health disorder as "Temporo-mandibular Disorders" and "TMD." An old cliché rings true here. "If you say something often enough, others will start to believe you." Now those who listen to the Dental profession, including the media, routinely accept the newer, popularly touted name, while orthopedic physicians remain silent about the Temporomandibular Joints.

But this is only part of the name changing story, for there is more that needs to be addressed.

Concomitant with dropping "Joint" and "J," a more subtle name change was taking place. "Dental Stress" was now becoming known as "Mental Stress," and with it a whole new concept of the "profile of a TMJ Patient" as a person [read Woman] with an ever present psychosocial behavioral problem was forming.

As JJAMD's Founders, we have steadfastly resented and resisted these name changes, and continuously bring this to the attention of the Dental profession and TMJ patients. We receive over 5,000 letters and calls each year from TMJ patients. We do not know of a single patient who refers to her/his health disorder as anything but "TMJ." We do not know one patient who has been helped or cured by all the name changing.

In JJAMD's testimony before the NIH/NIDR Blue Ribbon Panel in January 1993, we literally begged them to "...help stop the madness of name changing and go back to the historical name and acronym to better deal with all of the realities of this disorder if you are sincere in the mission to help foster knowledge, awareness, and to help alleviate 'The TMJ Dilemma' and its terrible burden on society."

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JJAMD continues to use only the historical name

and acronym -- "Temporomandibular Joints," the acronym "TMJ" and the consumer-friendly term, "Jaw Joints."

We are proud of our efforts to effect change and of our tenacity to only call TMJ, "TMJ" while referring to the "Jaw Joints," and dealing with all facets of this multifaceted medical/dental disorder. In so doing, we have always recognized that all the surrounding musculature, connective tissue, ligaments, nerves, and vascular systems are involved as they are with other joints in the body. We have always maintained that the biggest difference between the Jaw Joints and all other joints in the body is that the TM Joints must move in five distinct ways and that they are involved with the muscles of mastication. A name change to TMD does nothing to clarify this dynamic.

Name Changing has Done Harm to the Patients and to the Health Professions

The professions, particularly the Dental profession, [with apologies to those dentists who want no part of this diffusion and confusion], their professional organizations and governmental research agencies have, over the years, tended to characterize TMJ as a "women's hysteria disease" replete with the things that this stereotypical bias conjures up. The "dental/mental" categorization, as we call it, has trivialized the women sufferers as little more than chronic complainers, welfare cheats, workers compensation malingerers, "stressed night-time tooth grinding psychosomatic bundles of nerve endings, and snarling hypochondriacs."

At least before this name changing and psychological profile, the TMJ patients had a single shred of credibility and respectability. That was that they had "TMJ" -- an acronym not only of the anatomical joint structure involved in their disorder, but of the malfunction, disease, or disorder to that structure and the structures that surround the joints and cause them to function. In that respect they had at least the dignity accorded to an Arthritis sufferer. It mattered not if the inflammation resulted from the structures surrounding the joint, or if degeneration had occurred in the joint itself. "Arthritis is Arthritis is Arthritis." An Arthritis sufferer, therefore, is not treated like a TMJ sufferer by any of the professional or societal groups. Instead, they receive the respect due a legitimate medical infirmity. The TMJ sufferer, on the other hand, endures the "implied guilt" that haunts and punishes the patient who is "accused" of psychosocial behavioral conduct. This is emphasized by the term "TMD" which accentuates the mental and psychosocial component as a perpetuating factor.

Why the Name Change?

Why then has the name, Temporomandibular Joint Disorders (TMJ), been changed to Temporo-mandibular Disorders (TMD)? We are told that it is to better identify an anatomical part, like the knee or the elbow, so that people will know what it means to have a problem with a whole anatomical part rather than one part like a Jaw Joint and its related muscles, ligaments, etc. (i.e. TMJ Disorders). Certainly it was not to better describe an existing anatomical structure since we know of

no anatomical structure called a "Temporomandibular." Perhaps someone has discovered a new piece of anatomy called, for example, a "Temporalus Mandibulus" or "TM" for short. This could account for a combination of the major muscle groups and the largest bone in the cranium.

For the purposes of this article, therefore, let us assume that "TMD" is a new structure called the "Temporalus Mandibulus" and the disorder to this new anatomical structure is also "TMD." Now, like the knee or the elbow, we have something we can sink our teeth into -- the good old TMD. Perhaps it can be entered as a belated offering to the Publishers of Gray's Anatomy for validation.

The literature is replete with various explanations for this change, none of which make any more sense to the authors than the zany explanations concocted above. Some of these "explanations" follow.

The National Institute of Dental Research (NIDR) Defines, Then Re-Defines "TMD"

"Chronic Orofacial Pain Syndromes.

Temporomandibular joint pain. The many names used to describe chronic pain associated with the Joint (TMJ) pain dysfunction syndrome, myofascial pain dysfunction (MPD) syndrome, Costen's syndrome, cranio-mandibular syndrome -- testify to the uncertainty surrounding the etiology and treatment of this chronic pain problem." [Challenges for the Eighties. National Institute of Dental Research Long Range Research Plan. NIH Publication. ]

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What's in a Name? (continued from Page 6)

"Chronic Orofacial Pain.

Temporomandibular Disorders. Many names have been used to describe chronic pain associated with the Temporomandibular joint and the muscles of mastication, including TMJ pain dysfunction syndrome, myofascial pain dysfunction syndrome, Costen's syndrome, and, more recently, TMD." [Broadening the Scope. Long-Range Research Plan for the Nineties. National Institute of Dental Research. National Institutes of Health. NIH Publication.]

As a result of the characterization of TMJ disorder as a component of orofacial pain, we feel that NIDR has kept TMJ within the boundaries of chronic pain and out of the dysfunction realm from which virtually all TMJ patients also suffer.

We brought this unfortunate oversight to the attention of the Blue Ribbon Panel hearing at NIDR in January 1993, at which our testimony was invited. We were told we made a difference, for we were successful in getting the Blue Ribbon Panel to recommend that TMJ intramural research be shared in a new clinic with the National Institute of Arthritis and Musculoskeletal Research. Maybe now, at least for the NIH intramural research program, the jaw joints will be considered like any other joints in the body. [Report of the Blue Ribbon Panel on Envisioning the Future of the National Institute of Dental Research Intramural Research Program. National Institute of Dental Research. March 1993.]

Some Explanations are Written in Strange Tongues

A recent article in the Journal of the American Dental Association (JADA) "clarifies" the naming situation in "Yogi Berra" English for easy translation. They explained, "Temporomandibular disorders encompass a group of musculoskeletal conditions that involve the joints, the masticatory musculature, or both. In any given patient, there may be several overlapping TM disorders, an orofacial pain condition mimicking a TM disorder or a concomitant TMD and non-TM disorder. The differential diagnosis becomes extremely important." (Author's note: the preceding sentence is reproduced exactly as printed.) [Current Status of Diagnostic Procedures for Temporomandibular Disorders. Norman D. Mohl, D.D.S., Ph.D.; D. Carl Dixon, D.D.S., M.S. JADA, Vol. 125, January 1994.]

Popular and Professional Publications are Confused by the Name Changing and, in turn, Confuse their Readers

The popular magazine American Health is presumably read by millions of Americans. They, too, recently took a shot at the name dilemma and, remarkably, told us how the TMD is often operated on surgically. This provides, at least, a recognition for the new anatomical structure we just named the "Temporalus Mandibulus." The article states, "One often overused form of TMD surgery is arthroscopy, a minimally invasive procedure that enables surgeons to reach and repair the disk via tiny scopes." Up to now, disk surgery has always been referred to as "TMJ" surgery, considering that it is

the temporomandibular joint being operated on.

Operating on a TMD must have been an exhilarating experience for the oral surgeon, especially since that anatomical structure was invented in this article. In a side bar to the article the author ruminates about a celebrated jaw joint implant victim. "Over time, she developed painful clicking in her jaw and severe headaches, subsequently diagnosed as temporomandibular joint disorder (TMD). After years of treatment and 20 surgical procedures, including two jaw implants..." Now we have Temporomandibular JOINT Disorder anagramed as TMD, and again surgery not for a TMJ Disorder but for a TMD Disorder. One wonders if the implants were intended to repair an overused muscle or a bad behavioral problem rather than a degenerated joint. American Health could be passed over as insufficiently scientific, but the surgery issue really heats up when TMDiary, an official publication of a dental TMJ/TMD Academy, advertises TMJ video tapes from their second mid-winter meeting in Palm Beach, Florida. Included in the listing of videos is one entitled, "Use of Laser Arthroscopy in TMD Treatment - Indications for its Use and Post Operative Results." Tabers' Cyclopedic Medical Dictionary defines an arthroscope as "an endoscope for examining the interior of a joint." What in the world is the dentist doing examining a patient with an arthroscope and engaging in post-operative treatment if it is not to repair the joint (TMJ)? Maybe he or she is going after the "behavior muscle," which appears to be part of the TMD.

Oh Yes! Behavior is Usually Linked to TMD -- But Why Give TMJ a Bad Rap?

American Health magazine quoted a prominent government health official as saying "the term TMD

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actually encompasses a wide range of neurological, muscular, behavioral and mechanical disorders with no single cause or single treatment." Once again, one wonders why the patient isn't called a "mental patient," instead of a "TMD" patient. If, on the other hand, stressful clenching of the teeth and consequent pressure on the jaw joints or associated muscles results in facial pain related to the TM joint and the muscles of mastication, why isn't the patient suffering from temporomandibular joint disorder [TMJ] -- a perfectly "respectable" disorder not requiring institutionalization. Could it be that dentists have found still another lucrative practice enhancement in the form of psychological tests and behavior modification often administered to TMJ patients, sometimes before the practitioner will accept a new patient? Or, could it be another smokescreen to cover iatrogenic causes that seem to so frequently become involved in TMJ treatment.

Could it also be that the type of behavioral problems really associated with TMJ are only "every day" problems, such as a physician or dentist hyperextending the jaw joints during medical or dental procedures without allowing for a "rest" period? Or perhaps the patients are hyperextending the joints when eating huge sub sandwiches?

Behavior has been the primary source of grant money for a large number of "dental scientists" who publish voluminous and ubiquitous studies on the psychosocial component of TMJ, and other "research" on the stressed out women TMJ sufferers. Of course, behavior and psychosis have been suggested from time immemorial in diseases ranging from Alzheimer's to Ulcers. One by one as the virus or bacterium is isolated, and the DNA is mapped, these "mental giants" of research have been discredited. TMJ as a newly popular disorder has attracted its share of amateur psychologists, and only recently have studies begun to appear discrediting the findings that TMJ patients are really "mental cases" who inflict pain upon themselves by grinding their teeth in their sleep.

For example the Spring/Summer issue of "TMDiary," contains an article entitled "Bruxism: Is Origin Occlusion or Psychogenic?" The author quotes from a review of the literature by Faulkner, "...little work had been attempted to document bruxism in a scientific manner until Dr. Bernard Jankelson reported in a study entitled, Physiology of Human Dental Occlusion." The author suggests that a study in which bruxism was artificially created immediately in patients fitted with a thin film of acrylic element over one or more of contacting teeth,"...indicates that the fact that bruxism can be produced artificially in patients may mean that it could be reduced or eliminated in others without altering the person's behavior." He goes on to cite other studies that question whether bruxism is related to behavior. Now, if the amateur dental psychologists lose Bruxism as a primary behavioral problem related to the onset of TMJ, it will mean the same type of catastrophe as the Celtics losing Larry Bird. What will they have to rely on next? Perhaps it will be the fact that nasty women always screw up their faces when they berate their dentists for grinding down their natural dentition to effect the "perfect smile;" thereby putting them into a chronic TMJ condition for life, as happened to one of the authors of this article.

In Some Cases Name Changing has Been Ignored or Ridiculed

In a new book, written by a TMJ patient the question of, "What is TMJ?" is answered somewhat peripatetically by saying, "Technically, the term "TMJ" refers to the temporomandibular, or jaw, joint itself. TMJ disorder refers to problems with those joints. To avoid confusion, medical professionals now refer to the disorder as TMD, or temporomandibular disorder, and use 'TMJ' to identify the joint or joints alone. Since so few people have any idea what TMD means, however, we opted to stick with the old term, TMJ, throughout this book."

The author is poorly served by a dentist writing in the Preface "TMJ properly stands for temporomandibular joint the neuro-muscular 'hinge' connecting the moveable lower jaw to the skull. But 'TMJ' has come to be used to describe a confusing and non-specific muddle of conditions and symptoms, all allegedly caused by a malfunction of the TM joint. Since the joint is rarely the cause of these symptoms, many prefer the term 'TMD' (temporomandibular dysfunction)."

Therefore it is plain to see that a confusing and non-specific "muddle of conditions" is much better described with a quasi-anatomical structure (TMD) than with a legitimate anatomical structure (the temporomandibular joint) which is moved by the surrounding musculature and ligaments, all of which could be contributing to the pain and dysfunction. Why?

The University of California at Berkeley Wellness Letter is perhaps the last place one might look for topical humor. Yet, they found this whole name changing business quite amusing. "In a linguistic upset you may have overlooked, temporomandibular joint (TMJ) syndrome was recently rechristened

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What's in a Name? (continued from Page 8)

temporomandibular disorder (TMD). The new moniker, it was hoped, would more accurately reflect the complexity of the disorder. Either way, the jaw-breaking term refers to jaw trouble: a grinding or clicking sound, plus pain or discomfort when you open your mouth -- a feeling that your jaw has come unhinged." [Either way, it is still the Jaw Joints that are involved.]

A Physician and Dentist Collaborate on a Definition of TMD

An otolaryngologist who co-authored an article with his father, a dentist whose bio reads "An internationally recognized authority on TMD," titled the article "Diagnostic Clues to Temporomandibular Joint Disorder." [Hudson Monitor, April 25, 1993 p. 49-52]. The article is arranged as a series of questions and answers.

To begin, the authors bravely launch their article with an answer to the question, "What is Temporomandibular Joint Disorder?" Their joint response to the Joint question is: "Temporomandibular Joint Disorder (TMD) describes impaired or abnormal articulation of the temporomandibular joint (TMJ) for whatever reason. This term replaces other terms seen in previous literature, such as "TMJ Syndrome," "TMJ Dysfunction," or "Myofascial Pain Disorder." In one fell swoop they swept away any trace of TMJ Nonetheless, the good doctors proceeded to use the term TMJ 20 more times in the article, blithely interchanging it with TMD, whether describing a joint or a myalgia. So much for straightening us out in the first paragraph.

Are the Muscles of Mastication Really Separable from the Function of the Jaw Joints?

While all of the above might cause one to question whether there is actually any relationship between the temporomandibular joint (TMJ) and the muscles of mastication, the medical illustration book, The Ciba Anatomical Drawings, by Frank Netter, M.D., actually pictures the muscles of mastication and the text states, "The muscles of mastication all pass across the temporomandibular joint. They are the major muscles, producing the other movements allowed at this joint." Obviously, the joint does not operate without the muscles of mastication and the muscles of mastication are useless if they don't move the joint.

This brings us right back to the point of this article. We maintain that whether or not there is any dislocation, degeneration, or arthritis in the joint, or whether the problem is with the muscles, ligaments, tendons or anything else that causes pain and/or dysfunction to the joint, or the surrounding structures, you have a TM Joint problem. (TMJ).

Why is it, therefore, so important to the dental profession to divorce the muscles of mastication from the Temporomandibular Joints when describing TMJ Disorder? We suggest the answer lies in the desire of the professions to disassociate themselves from the Joint and involve themselves in an oblique and fuzzy area of treatment involving neurology, behavioral medicine and muscle disorders.

Name Changing is Serious to the Patient

Is the name changing serious to TMJ patients and future TMJ patients? Absolutely! The obfuscation further distances the patients from health insurance reimbursement for a medical problem. It changes the character of their disorder from one that a little is known about to one that nobody knows anything about. It also robs them of their self-respect for a medical problem that could at least be diagnosed -- in exchange for a dental problem involving their mental health and psychosocial behavior.

Let's Go Back to the Beginning and Call it "TMJ"

The time to return to "TMJ" or to use a more descriptive and "patient-friendly" term has arrived. For the sake of all TMJ patients, we urge

the dentists, psychologists, researchers, medical writers, NIDR, and the ADA, to return to "Temporomandibular Joint Disorder(s)." ◊◊