BlueCross and BlueShield of Montana Medical Policy/Codes
Temporomandibular Joint Dysfunction (TMD)
Chapter: Dental
Current Effective Date: March 21, 2011
Original Effective Date: September 01, 2007
Publish Date: March 21, 2011
Revised Dates: March 21, 2011
Description

Temporomandibular joint (TMJ) disorders refer to a group of disorders characterized by pain in the TMJ and surrounding tissues. Initial conservative therapy is generally recommended; there are also a variety of non-surgical and surgical treatment possibilities for patients whose symptoms persist.

Background

Temporomandibular joint (TMJ) dysfunction (also known as TMJ disorders) refers to a cluster of problems associated with the temporomandibular joint and musculoskeletal structures. The etiology of TMJ disorders remains unclear and is believed to be multifactorial. TMJ disorders are often divided into two main categories: articular disorders (e.g., ankylosis, congenital or developmental disorders, disk derangement disorders, fractures, inflammatory disorders, osteoarthritis and joint dislocation) and masticatory muscle disorders (e.g., myofacial pain, myofibrotic contracture, myospasm and neoplasia).

There are no generally accepted criteria for diagnosing TMJ disorders. It is often a diagnosis of exclusion and involves physical examination, patient interview, and dental record review. Diagnostic testing and radiologic imaging is generally only recommended for patients with severe and chronic symptoms.

Symptoms attributed to TMJ dysfunction are varied and include but are not limited to clicking sounds in the jaw; headaches; closing or locking of the jaw due to muscle spasms (trismus) or displaced disc; pain in the ears, neck, arms, and spine; tinnitus; and bruxism (clenching or grinding of the teeth).

For many patients, symptoms of TMJ dysfunction are short-term and self-limiting. Conservative treatments, such as eating soft foods, rest, heat, ice, and avoiding extreme jaw movements, and anti-inflammatory medication, are recommended prior to consideration of more invasive and/or permanent therapies, such as surgery.

Policy

Prior authorization for surgical treatment of TMJ is recommended. To authorize, call Blue Cross and Blue Shield of Montana (BCBSMT) Customer Service at 1-800-447-7828 or fax your request to the Medical Review Department at 406-437-7863. A retrospective review is performed if services are not prior authorized.

BCBSMT considers the following diagnostic procedures medically necessary in the diagnosis of TMJ dysfunction:

  • Diagnostic x-ray, tomograms, and arthrograms
  • Computed tomography (CT) scan or magnetic resonance imaging (MRI) (in general, CT scans and MRIs are reserved for pre-surgical evaluations)
  • Cephalograms (x-rays of jaws and skull)
  • Pantograms (x-rays of maxilla and mandible).

Cephalograms and pantograms should be reviewed on an individual basis.

Coverage for Nonsurgical treatment of TMJ is contract specific. If the member or group contract covers nonsurgical treatment of TMJ BCBSMT considers the following medically necessary in the treatment of TMJ dysfunction:

  • Intra-oral reversible prosthetic devices/appliances (encompassing fabrication, insertion, and adjustment)
  • Pharmacologic treatment (such as anti-inflammatory, muscle relaxing, and analgesic medications).

Coverage for surgical treatment of TMJ is contract specific. If the member or group contract covers surgical treatment of TMJ BCBSMT considers the following surgical treatments medically necessary in the treatment of TMJ dysfunction:

  • Arthrocentesis
  • Manipulation for reduction of fracture or dislocation of the TMJ
  • Arthroscopic surgery in patients with objectively demonstrated (by physical examination or imaging) internal derangements (displaced discs) or degenerative joint disease who have failed conservative treatment
  • Open surgical procedures (when TMJ dysfunction is the result of congenital anomalies, trauma, or disease in patients who have failed conservative treatment) including, but not limited to arthroplasties; condylectomies; meniscus or disc plication and disc removal.

Investigational

  BCBSMT considers the following diagnostic procedures are considered investigational in the diagnosis of TMJ dysfunction:

  • Electromyography (EMG), including surface EMG
  • Kinesiography
  • Thermography
  • Neuromuscular junction testing
  • Somatosensory testing
  • Transcranial or lateral skull x-rays
  • Sonogram (ultrasonic Doppler auscultation)
  • Intra-oral tracing or gothic arch tracing (intended to demonstrate deviations in the positioning of the jaws that are associated with TMJ dysfunction)
  • Muscle testing
  • Standard dental radiographic procedures
  • Range of motion measurements
  • Computerized mandibular scan (this measures and records muscle activity related to movement and positioning of the mandible and is intended to detect deviations in occlusion and muscle spasms related to TMJ dysfunction). 

BCBSMT considers the following nonsurgical treatments investigational in the treatment of TMJ dysfuction:

  • Electrogalvanic stimulation
  • ontophoresis
  • Biofeedback
  • Ultrasound
  • Devices promoted to maintain joint range of motion and to develop muscles involved in jaw function
  • Orthodontic services
  • Dental restorations/prostheses
  • Transcutaneous electrical nerve stimulation (TENS)
  • Percutaneous electrical nerve stimulation (PENS)
  • Physical therapy, including diathermy, infrared and heat and cold treatment, and manipulation
  • Acupuncture

BCBSMT considers the following surgical treatment investigational in the treatment of TMJ dysfuction:

  • Arthroscopy of the TMJ for purely diagnostic purposes

Exclusions

BCBSMT considers the following dental services not eligible for medical benefits including, but not limited to:

  • Occlusal adjustment;
  • Full mouth reconstruction;
  • Dentures;
  • Orthodontia (excluded in most group and member contracts);
  • Appliance or restoration to increase vertical dimension or restore occlusion;
  • Devices promoted to maintain joint range of motion and to develop muscles involved in jaw function.

Rationale

Literature Review

When the policy was created, the MEDLINE database was searched for the period January 1992 through March 1995. An updated literature search was not performed until 2010, at which time the literature was searched from March 1995 through April 2010. This literature review concentrated on identifying systematic reviews and meta-analyses. For treatment of TMJ disorders, the focus was on studies that compared novel treatments to conservative interventions and/or placebo controls (rather than no-treatment control groups) and that reported pain reduction and/or functional outcomes, e.g., jaw movement.

Diagnosis of temporomandibular dysfunction

Systematic reviews on magnetic resonance imaging (MRI) and surface electromyography to diagnose TMJ dysfunction were identified. The most recent systematic review on MRI was published in 2009 by Koh and colleagues and included 23 studies. (1) Eight of the 23 studies found a relationship between a clinical and MRI diagnosis. The authors found substantial variability in study design, methods of clinical examination, and diagnostic criteria and therefore could not pool study findings. The Koh review concluded that there is no clear evidence of a relationship between clinical and MRI diagnosis and findings and additional studies using improved methodologies.

The authors of a systematic review on surface electromyography found a lack of literature on the accuracy of this method of diagnosis, compared to a gold standard (i.e., comprehensive clinical examination and history-taking). (2) They concluded that there is insufficient evidence that electromyography can accurately separate individuals with facial pain from those without pain but that the technique may be useful in a research setting.

Treatment of temporomandibular dysfunction

A 2010 article by List and colleagues was a review of systematic reviews on treatments for TMJ dysfunction published between January 1 1987 and September 8 2009. (3) The authors identified 30 reviews; there were 23 qualitative systematic reviews and 7 meta-analyses. Eighteen of the systematic reviews included only randomized controlled trials (RCTs), 3 included case-control studies, and 9 included a mixture of RCTs and case series. There was inconsistency in how TMJ disorders were defined in the primary studies and systematic reviews, and several of the reviews addressed the related diagnoses of bruxism, disc replacements, and myofascial pain. Twenty-nine of the systematic reviews had pain intensity or pain reduction as the primary outcome measure, and 25 reported clinical outcome measures such as jaw movement or jaw tenderness on palpation. The authors divided the treatments into 5 categories (some studies were included in more than 1 category). These categories and the main findings are as follows:

  1. Occlusal appliances, occlusal adjustment, and orthodontic treatment (10 articles): 6 systematic reviews did not find significant benefit compared to other treatments, 4 found no benefit compared to a placebo device, and 3 found that occlusal therapy was better than no treatment.
  2. Physical therapy including acupuncture, TENS, exercise and mobilization (8 articles): 4 reviews found no significant benefit of acupuncture over other treatments, 1 found no difference between acupuncture and placebo treatment, and 3 found that acupuncture was better than no treatment.
  3. Pharmacologic treatment (7 articles): treatments found to be superior to placebo were analgesics (2 reviews), clonazepam or diazepam (3 reviews), antidepressants (4 reviews) and hyaluronate (1 review). The last review also found hyaluronate and corticosteroids to have a similar effect.
  4. Maxillofacial surgery (4 articles): three reviews evaluated surgery for patients with disc displacements and the fourth addressed orthognathic surgery in patients with TMJ disorder. Reviews of surgical treatments generally included lower level evidence, e.g., case series, and did not always compare surgery to a control condition. One systematic review found a similar effect of arthrocentesis, arthroscopy, and physical therapy.
  5. Behavioral therapy and multimodal treatments (6 articles): two reviews found biofeedback to be better than active control or no treatment, 1 review found a combination of biofeedback and cognitive-behavioral therapy to be better than no treatment, and 2 found a combination of biofeedback and relaxation to be better than no treatment. One review found that the effects of biofeedback and relaxation were similar.

Overall, the authors concluded that there is insufficient evidence that electrophysical modalities and surgery are effective for treating TMJ dysfunction. They found some evidence that occlusal appliances, acupuncture, behavioral therapy, jaw exercise, postural training, and some medications can be effective in reducing pain for patients with TMJ disorders. However, the authors note that most of the systematic reviews they examined included primary studies with considerable variation in methodologic quality and thus, it is not possible to make definitive conclusions about the effectiveness of any of the treatments.

Key relevant studies were also examined. Three systematic reviews by the Cochrane Collaboration that evaluated treatments for TMJ disorders were identified.

A Cochrane review by Guo and colleagues, last updated in 2009, identified two RCTs with a total of 81 patients that evaluated the effectiveness of arthrocentesis and lavage for the treatment of TMJ dysfunction. (4) Data were pooled only for the outcome maximum incisal opening. A meta-analysis of the two trials found a weighted mean difference of -5.28 (95% confidence interval [CI] -7.10 to -3.46) in favor of arthroscopy compared to arthrocentesis. The authors concluded that there was insufficient evidence from high-quality RCTs to draw conclusions about the effectiveness of arthrocentesis.

Koh and Robinson identified 3 trials that evaluated treatment of TMJ disorders with occlusal adjustment; a total of 193 patients completed the trials. (5) Due to differences in outcomes and reporting scales, findings were not pooled. Individual trials did not find significant differences in symptom reduction between occlusal adjustment and control groups. The authors concluded that there is insufficient evidence on occlusal adjustment as a treatment for TMJ.

Al-Ani and colleagues identified 12 RCTs that compared stabilization splint therapy for TMJ dysfuction to a control intervention. (6) There was wide variability in the comparison interventions and no standardization of outcomes; thus, results of the studies were not pooled. The authors stated that they found little evidence of a difference in the effectiveness of stabilization splint therapy for patients with pain associated with TMJ dysfunction. They further stated that there is some evidence that stabilization splint therapy may be more beneficial for reducing pain severity than no treatment.

In addition to the Cochrane reviews, two other relevant systematic reviews were identified; both addressed acupuncture as a treatment for TMJ. The more recent review, published in 2006, identified 6 RCTs; one study was from the U.S. and the remainder were conducted in Sweden. (7) The U.S.-based study, by Goddard and colleagues, was the only one to use a sham comparison. However, that study included only 18 patients, involved a single treatment session, and assessed efficacy immediately after treatment, not longer-term. There was no significant difference in pain reduction between groups; pain was significantly lower in both the active and sham acupuncture groups after treatment, compared to before (70% vs. 50%, respectively experienced a significant reduction in pain). The Swedish studies tended to find similar effectiveness of acupuncture and occlusal splints, and both of these interventions were more effective than no treatment. The authors concluded that acupuncture was similar in effectiveness to occlusal splints but that, due to the methodologic limitations, e.g., lack of blinding in most studies, further studies are needed to rigorously evaluate acupuncture as a treatment for TMJ dysfunction.

An RCT was identified that directly compared four treatments for TMJ. (8) A total of 106 patients were randomized; 29 to a medical management group (nonsteroidal anti-inflammatory drugs for 3-6 weeks plus muscle relaxants and over-the-counter analgesics, as needed), 25 to a rehabilitation group (medical management along with a intra-oral orthotic, physical therapy and cognitive-behavioral therapy), 26 to an arthroscopy group, and 26 to an arthroplasty group. Ten patients withdrew before receiving treatment. An intention-to-treat analysis was performed at 5 years and 8 of 10 withdrawals were included in their assigned group. The study was single-blind (blinded outcome assessment). The two primary outcome measures were the craniomandibular index of pain, and function on the symptom severity index; both range from 0 to 1, with 0 being the lowest value. There was not a significant difference among groups in either of the 2 primary outcomes at any follow-up visit, including the 6-month, 1-, 2-, and 5-year visits. For example, mean scores on the symptom severity index at 1 year were 0.28 in the medical management group, 0.31 in the rehabilitation group, 0.30 in the arthroscopy group, and 0.20 in the arthroplasty group (p=0.37). Corresponding scores on the craniomandibular index at 1 year were 0.20, 0.20, 0.21, and 0.23, respectively (p=0.86).

Summary

Other than on acupuncture, the literature search did not identify studies that would lead to changes in the policy statements as written at the time of the last policy update in 2007. The primary conclusion from the systematic review of studies on acupuncture for TMJ dysfunction is that evidence on efficacy is insufficient due to a lack of rigorous trials. Thus, acupuncture for treatment of TMJ dysfunction can be considered investigational.

Technology Assessments, Guidelines, and Position Statements

American Society of Temporomandibular Joint Surgeons: Consensus clinical guidelines, published in 2001, focus on TMJ associated with internal derangement and osteoarthritis. (9) For diagnosis of this type of TMJ dysfunction, a detailed history and, when indicated, general physical examination are recommended. Imaging of the TMJ and associated structures is also recommended. Options for basic radiography to provide information on temporal bone and condylar morphology include use of plain films, panoramic films, and tomograms. Also recommended is imaging of the disc and associated soft tissue with MRI or arthrography. Other diagnostic procedures that may be indicated include computed tomography, MRI, arthrography (for selected cases) and isotope bone scans.

Nonsurgical treatment should be considered first for all symptomatic patients with this condition. Recommended treatment options include change in diet, nonsteroidal anti-inflammatory drugs, maxillomandibular appliances, physical therapy, injections of corticosteroids or botulinum toxin, and behavior modification. If adequate symptom relief does not occur within 2-3 weeks, surgical consultation is advised. The guideline states that the following surgical procedures are considered to be accepted and effective for patients with TMJ associated with internal derangement/osteoarthritis:

  • Arthrocentesis
  • Arthroscopy
  • Condylotomy
  • Arthrotomy (prosthetic joint replacement may be indicated in selected patients who have severe joint degeneration, destruction or ankylosis)
  • Coronoidotomy/coronoidectomy
  • Styloidectomy

American Dental Association: Selected statements from their dental practice parameters for TMJ, revised in 1997 (10), are:

  • The key element in the design of this set of parameters for temporomandibular (TM) disorders is the professional judgment of the attending dentist, for a specific patient, at a specific time
  • nitially the dentist should select the least invasive and most reversible therapy that may ameliorate the patient’s pain and/or functional impairment.
  • Any treatment performed should be with the concurrence of the patient and the dentist…
  • The dentist should evaluate the effectiveness of initial therapy prior to considering more invasive and/or irreversible therapy.
  • he dentist should counsel the patient that TM disorders are often managed, rather than resolved, and that symptoms of TM disorders may persist, change, or recur intermittently.
  • The patient should be informed that the success of treatment is often dependent upon patient compliance with prescribed treatment and recommendations for behavioral modifications. Lack of compliance should be recorded.
  • When articular derangement and/or condylar dislocation has been determined to be the etiology of the patient’s pain and/or functional impairment, manual manipulation of the mandible may be performed by the dentist.
  • Oral orthotics (guards/splints) may be used by the dentist to enhance diagnosis, facilitate treatment or reduce symptoms.
  • The dentist should periodically evaluate oral orthotics (guards/splints) for their effectiveness, appropriateness and possible risks associated with continued use.
  • Before restorative and/or occlusal therapy is performed, the dentist should attempt to reduce, through the use of reversible modalities, the neuromuscular, myofascial and temporomandibular joint symptoms.
  • The dentist may replace teeth, alter tooth morphology and/or position by modifying occluding, articulating, adjacent or approximating surfaces, and by placing or replacing restorations (prostheses) to facilitate treatment.
  • Transitional or provisional restorations (prostheses) may be utilized by the dentist to facilitate treatment.
  • Intracapsular and/or intramuscular injection, and/or arthrocentesis may be performed for diagnostic and/or therapeutic purposes.’
  • Orthodontic therapy may be utilized to facilitate treatment.
  • Orthognathic surgery may be performed to facilitate treatment.
  • When internal derangement or pathosis has been determined to be the cause of the patient’s pain and/or functional impairment, arthroscopic or open resective or reconstructive surgical procedures may be performed by the dentist.

Medicare National Coverage

No national coverage determination.

Rationale for Benefit Administration

This dental policy was developed through consideration of peer reviewed dental literature, FDA approval status, accepted standards of dental practice in Montana, Technology Evaluation Center evaluations, other Blue Cross and Blue Shield plan policies and the concept of medical necessity.

The purpose of dental policy is to guide coverage decisions and is not intended to influence treatment decisions. Providers are expected to make treatment decisions based on their dental judgment. Blue Cross and Blue Shield of Montana recognizes the rapidly changing nature of technological development and welcomes provider feedback on all dental policies.

When using this policy to determine whether a service, supply or device will be covered please note that member contract language will take precedence over dental policy when there is a conflict.

ICD-9 Codes

524.60, 524.62, 524.69, 524.8, 526.89, 526.9, 715.90, 722.1 – 722.2, 959.0

Procedural Codes: D0160, D0320, D0321, D0322, D0470, D7810, D7820, D7830, D7840, D7850, D7852, D7854, D7850, D7858, D7860, D7865, D7870, D7871, D7872, D7873, D7874, D7875, D7877, D7880, D7991, D9940, D9950, 20605, 21010, 21116, 21240, 21242, 21050, 21060, 21073, 21240, 21242, 21243, 29800, 29804, 70328, 70330, 70332, 70336, 70350, 70355, 97010, 97024, 97026, E1700, E1701, E1702
References
  1. Koh KJ, List T, Petersson A et al. Relationship between clinical and magnetic resonance imaging diagnoses and findings in degenerative and inflammatory temporomandibular joint diseases: a systematic literature review. J Orofac Pain 2009; 23(2):123-39.
  2. Klasser GD, Okeson JP. The clinical usefulness of surface electromyography in the diagnosis and treatment of temporomandibular disorders. J Am Dent Assoc 2006; 137(6): 763-71.
  3. List T, Axelsson S. Management of TMD: evidence from systematic reviews and meta-analyses. J Oral Rehab 2010; 37(6):430-51.
  4. Guo C, Shi Z, Revington P. Arthrocentesis and lavage for treating temporomandibular joint disorders. Cochrane Database Syst Rev 2009; (4):CD004973.
  5. Koh H, Robinson P. Occlusal adjustment for treating and preventing temporomandibular joint disorders. Cochrane Database Syst Rev 2003; (1):CD003812.
  6. Al-Ani MZ, Davies SJ, Gray RJ et al. Stabilisation splint therapy for temporomandibular pain dysfunction syndrome. Cochrane Database Syst Rev 2004; (1):CD0028778.
  7. Fink M, Rosted P, Bernateck M et al. Acupuncture in the treatment of painful dysfunction of the temporomandibular joint-a review of the literature. Forsch Komplementmed 2006; 13(2):109-15.
  8. Schiffman EL, Look JO, Hodges JS et al. Randomized effectiveness study of four therapeutic strategies for TMJ closed lock. J Dent Res 2007; 86(1):58-63.
  9. American Society of Temporomandibular Joint Surgeons. Guidelines for diagnosis and management of disorders involving the temporomandibular joint and related musculoskeletal structures. Available online at: http://astmjs.org/guidelines.html . Last accessed May 2010.
  10. American Dental Association. Temporomandibular (Craniomandibular) Disorders. Practice Parameters. Revised 1997. Available online at: http://www.ada.org/1958.aspx . Last accessed May 2010.
History
03/21/2011: Added investigational surgical, diagnositc, nonsurgical treatments. Added rationale and references.
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Temporomandibular Joint Dysfunction (TMD)