Terminologies describing a wide area of dysfunction and pain in the head, neck, and temporomandibular joint (TMJ) lack definitive description. Not only can the profession not agree on the definition of the terms, the leading government dental agency National Institute of Dental and Craniofacial Research (NIDCR) stated that there is no widely accepted, standard test to correctly identify TMJ dysfunctions. If testing is ordered, the NIDCR asks the patient to request another independent opinion. It is so much a problem that quite often health care consultants recommend no payment for dentists treating TMJ diseases. ADA's website has little information about TMJ diseases and facial pain. The same can be said for websites of the National Institutes of Health (NIH), American Medical Association (AMA), Centers for Disease Control (CDC), Academy of General Dentistry (AGD), the Pankey Institute, and the Mayo Clinic. Current literature also contains a confusing array of definitions such as CFP (craniofacial pain), CFD (craniofacial disorder), MFP (myofascial pain), MPD (myofascial pain disorder), CMD (craniomandibular disorder), CMP (craniomandibular pain), CMDS (craniomandibular disorders), TMD (temporomandibular disorder/dysfunction), TMJ (temporomandibular joint), TMJD (temporomandibular joint disorder/dysfunction), OFD (orofacial disorder, OFP (orofacial pain), MMD (masticatory muscle disorder), AFP (atypical facial pain), and many others. It seems like each practitioner has coined his/her own term when writing articles. Still other practitioners will use the terms coined by their colleagues of influence in their particular fields. The terminology used is like a moving, morphing target: each term means something to someone but may mean something totally different to another. From this primordial soup of terminology, a most unexpected thing happened. Two definitions may actually have a fixed meaning.
1. NIH in the Healthy People 20101 project fixed a definition to the term CFP, craniofacial pain. Craniofacial pain can cover everything from dysfunction to pain and from tooth decay to genetics of the head and face.
2. NIDCR defined TMD (temporomandibular disorders) as a group of conditions affecting the jaw joints and the muscles that control the jaw complex.
It would be difficult not to accept the NIH's definition of craniofacial pain (CFP), since CFP covers everything inclusive of the head, face, and jaw. Thus CFP is the umbrella term of all other terms (i.e., CFD, CMP, MFP, MPD, CMD, CMDS, TMJ, TMJD, TMJP, OFD, OFP, MMD, TMD) and any newly coined terms we may have missed. In the NIH's defined term of CFP (craniofacial pain), the NICDR’s definition of TMD is a part of CFP and covers two major areas. They are the dysfunctions and diseases of the TM joint and the jaw musculature. If this parameter is followed, all other terms used to describe TM joint diseases should fit into one of two groups.
Group I describes diseases of the TM joint. TMJD (temporomandibular joint dysfunction / disorder) is a functional problem of the mandible, specifically related to the temporal area and the TM joint (in other words, T represents occlusion, M represents muscle, J represents joint(s), and D represents dysfunction). This is the same way TMD is defined by NIDCR. TMJP (temporomandibular joint pain) is a description of pain in the TM joint area. TMJ (temporomandibular joint) is an anatomical term only. It should never be used to describe a disease, dysfunctional problem, pain, or syndrome. TM joint disorders can be diagnosed by tomography, MRI, or arthrography. Group II includes all the terms related to muscles and has two subgroups. All muscle problems can be tested using muscle palpation, ROM (range of motion) measurements, manual or computerized, and nerve testing. Subgroup one describes the dysfunctions involving primarily the jaw muscles. All terms ending with a D can fit into this group: CFD, MPD, CMD, CMDS, OFD, MMD. CFD (craniofacial dysfunction) describes the dysfunction between the system related to the face and head. The cranium does not have an easily measurable ROM, so any measurable dysfunction is in the mandible ROM. Functional disorders are related to facial structure and are more than likely related to how the teeth fit together, how the muscles function, and how the joint functions. MPD (myofascial pain dysfunction) describes a functional problem of the mandible related to disturbed occlusal mechanics, primarily muscular in origin.3 CMD (craniomandibular disorder) also describes a functional problem of the mandible related to how the teeth fit together, how the muscles function, and how the joint functions.
CMDS (craniomandibular dysfunction syndrome) describes a collage of symptoms indicating abnormal conditions, including disease and psychological disorders. The known cause of such is not yet understood. TMD (temporomandibular dysfunction) describes the dysfunction between the system related to the temporal region of the head and lower jaw. NIDCR defines TMD as a group of conditions affecting the jaw joints and the muscles that control the jaw. MMD (masticatory muscle disorder) is defined by Okeson2 as muscle splinting, local muscle soreness, trigger point pain, myospasm, and centrally mediated myalgia. Subgroup two includes pain that results from muscular dysfunction. All terms ending with P can be included in this group: MFP, CMP, AFP, and OFP. MFP (myofascial pain) is pain in the fascial system of the body involving the muscles. Fascia is the connective tissue found everywhere in the body that holds organs in place. When fascia malfunctions due to injury, illness, surgery, or poor posture, it becomes tight and binds down, resulting in abnormal pressure on nerves, muscles, bones, or organs. Restriction in one region can pull the fascia in any other direction. In TMJ disorders, professionals tend to look primarily at the musculature of the upper body and head. While this is the main area of pain, the rest of the body cannot be overlooked. Myofascial pain occurs throughout the body and affects the healing process. CMP (chronic myofascial pain) is myofascial pain involving the fascia and muscles of the head and neck all the way to the toes. OFP (orofacial pain) is pain involving the teeth and face, including facial muscles. AFP (atypical facial pain) is pain occurring in the area around the trigeminal nerve with no specific cause.4 What is the proper name for the disorders relating to the structures of the TMJ and recognized by all health care organizations? The CRANIO in its January 2005 issue assumed a leadership role in identifying the confusion that exists involving the definitions of orofacial pain and myofascial pain related to TMJD diagnosis and treatment. Dr. Joseph Cohen5 wrote an editorial asking all the leaders of various groups to communicate with each other to help achieve common goals that will help our patients get the care they need. Maybe the American Alliance of TMD Organizations (Alliance) can pick up the challenge of CRANIO and Dr. Joseph Cohen (president, American Academy of Orofacial Pain) and take the first step to get a clear definition of terms to promote a unified understanding of terminology. The Alliance might also consider having a joint meeting so that members of all the various organizations could attend lectures outside their own organization to get beyond the confusion and come to a better understanding.
References
1. Healthy People 2010: Oral health toolkit (complete report). Chapter 3, Oral health terminology; US Department of Health and Human Services. January 2000:3.
2. Okeson J: Management of temporomandibular disorders and occlusion. 4th ed. St. Louis: Mosby Year Book, Inc., 1998.
3. Travell JG, Simmons DG: Myofascial pain and dysfunction: the trigger point manual. Baltimore: Williams and Wilkins Co., 1983.
4. Halsey JH: Atypical facial pain. www.emedicine.com/neuro/topic25.htm.
5. Cohen JR: Working together toward common goals. J Craniomandib Pract 2005; 23(1):1.
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