BlueCross and BlueShield of Montana Medical Policy/Codes
Temporomandibular Joint (TMJ) Disorders (TMJD)
Chapter: Surgery: Procedures
Current Effective Date: July 18, 2013
Original Effective Date: September 01, 2007
Publish Date: April 18, 2013
Revised Dates: This policy is no longer scheduled for routine literature review and update. March 21, 2011; April 17, 2013
Description

The temporomandibular joints (TMJ) are located on either side of the face, just in front of the ears, and are formed by the mandibular condyle of the lower jaw fitting into the mandibular fossa of the temporal bone of the skull.  These two bones are separated from direct contact by a fibrous disc, sometimes referred to as a meniscus, which functions as a moving shock absorber and stabilizer between the condyle and fossa.  The articulating surfaces of the TMJ are lined with dense fibrous connective tissue that has a greater ability to repair itself than the hyaline cartilage that lines most other synovial joints.  The TMJ provides both hinging and sliding movement by way of a group of skeletal muscles referred to as the muscles of mastication (chewing).  These muscles allow functional behaviors such as swallowing, talking, and mastication, as well as non-functional (parafunctional) behaviors defined as bruxism, which is clenching of the teeth, associated with forceful lateral or protrusive jaw movements, resulting in rubbing, gritting, or grinding together of the teeth, usually during sleep. 

Temporomandibular disorders (TMD, or TMJD) encompass a cluster of related disorders in the masticatory system that has many common symptoms.  An estimated 75% of the U.S. population has experienced one of more symptoms of TMJD; approximately 5-10% of the U.S. population will require professional treatment.  TMJD usually involves more than one symptom and rarely has a single cause; most TMJD symptoms are temporary and require little or no professional intervention.  The most common symptom is pain or discomfort in or around the ear, jaw joint, and/or muscles of the jaw, face, temples, and neck.  Pain may arise suddenly, or progress over months to years with intermittent frequency and intensity.  Other symptoms include clicking, popping, grating (crepitus), locking, limited or deviant jaw opening, and chewing difficulties.

There are two basic types of TMJD; myogenous and arthrogenous.  Myogenous TMJD is muscle-related, and usually results from overwork, fatigue or tension of the jaw and supporting muscles. Arthrogenous TMJD is joint-related and usually results from inflammation, disease or degeneration of the hard or soft tissues within the TMJ; most commonly capsulitis, synovitis, disc dislocation (internal derangement), or degenerative arthritis.  Bruxism and head/neck muscle tension, while not scientifically proven causes of TMJD, may perpetuate TMJD symptoms and may need to be controlled to manage TMJD.  Although dental malocclusion has historically been viewed as a cause of TMJD, recent research studies do not confirm that conclusion.  Scientific studies have indicated a higher level of anxiety and emotional stress in TMJD patients, but have not established whether anxiety and depression were the cause of, or were caused by, TMJD. 

TMJD evaluation may include a comprehensive history of all symptoms, including dental and psychological history; a comprehensive physical examination of the TMJ’s, cervical spine, jaw/head/neck muscles, neurological-neurovascular structures, teeth and gums; a psychological evaluation, including a brief interview and testing when indicated; additional tests as indicated, including X-rays, diagnostic imaging, etc.

Since there is no known cure for TMJD, management of symptoms is similar to management of other orthopedic or rheumatologic disorders.  The goals of TMJD management include decrease in adverse loading or pressure on the jaw joints, and restoration of jaw function and normal daily activities.  Because signs and symptoms of TMJD may be temporary and self-limiting, special effort should be made to avoid aggressive or nonreversible therapy such as surgery or extensive dental or orthodontic treatment.  Conservative management techniques, such as behavior modification, physical therapy, medication, jaw exercise, and orthotics have proven to be safe and effective in the majority of cases.  Most patients achieve good long-term relief with conservative (reversible) therapy; scientific research demonstrates that over 50% of TMJD patients treated conservatively have few or no ongoing symptoms of TMJD. 

Behavior modification is often necessary because maladaptive behavior and persistent habits, such as tooth clenching or nail biting, may play a significant role in aggravating and perpetuating TMJD symptoms.  Also, psychological or emotional conflicts can be an integral component in TMJD and chronic pain behavior, and referral to a mental health professional in conjunction with reversible physical treatment may be indicated.  Physical therapy exercises and mobilization techniques can help to maintain normal muscle and joint function, improve range of motion, and increase muscle strength and coordination. Occlusal therapy, including occlusal adjustment, orthodontic treatment, restorative dentistry, and orthognathic surgery has little support in scientific literature for routine use in treatment of TMJD and is rarely necessary; generally, irreversible occlusal changes should be discouraged.  Oral orthopedic appliances, such as splints, orthotics, night guards, etc, are routinely used for TMJD management.  These are designed to redistribute the occlusal forces, reduce mobility of teeth, and reduce bruxism.  TMJ arthrocentesis lubricates the joint surfaces and reduces inflammation.  Corticosteroids or anti-inflammatory agents may be injected into the joint following arthrocentesis, and gentle manipulation may be performed to improve jaw range of motion. 

Surgical treatment can be effective for specific disorders, but should only be considered after reasonable reversible treatment techniques have failed.  TMJ surgical procedures include closed techniques (arthroscopy) and open techniques (arthrotomy).  Arthroscopy may be effective in treatment of conditions caused by displaced discs, fibrous adhesions, and arthritis.  However, recent studies suggest that TMJ arthrocentesis may be as effective as arthroscopic surgery.  Arthrotomy may be indicated for severe fibrous adhesion removal, ankylosis, tumor removal, chronic dislocation, painful non-reducing disc dislocation, and severe osteoarthritis that has not been responsive to reversible treatment.

Patient self-care techniques may be helpful.  These include:

  • limited jaw opening; and
  • avoidance of
    1. heavy chewing (e.g., gum, bagel, tough meat),
    2. teeth grinding and clenching,
    3. leaning or sleeping on the jaw,
    4. tongue thrusting,
    5. chewing on fingernails or non-food items, and/or
    6. playing musical instruments that stress, retrude or strain the jaw.

The American Academy of Orofacial Pain strongly cautions against treatments designed to permanently change the bite or to reposition the jaw with orthodontics or reconstruction.  The TMJ Association, LTD is a national non-profit organization whose mission is to improve the diagnosis, care and treatment of patients affected by TMJD through fostering research, education, and prevention of TMJ problems.  On their informational web site, the TMJ Association notes that TMJ implants to replace all or part of the jaw joint have failed in a large number of patients who then experience serious complications that require further treatment and often additional surgeries.  The following list is excerpted from the TMJ Association’s list of symptoms that are frequently reported by TMJ implant patients, which the Association specifies may or may not be related to jaw implants:

  • resorption or degeneration at the end of the jaw bone (the condyle) and the part of the skull where the jaw bone is inserted (the fossa); the mandibular bone, or jaw, described as "melting" or "soft"; skull penetration (holes in the skull);
  • disfigurement or deformity of the face;
  • pain and dysfunction in the facial muscles;
  • weakness and/or diminished muscle strength;
  • lack of coordination;
  • visual disturbances, including reading problems, snow blindness, blurred vision, blindness;
  • memory loss, confusion, inability to think clearly;
  • seizures and/or blackouts;
  • swollen lymph nodes/glands (e.g., neck, behind ears, under arms, groin);
  • abnormalities of the parotid glands (the salivary glands, located below and in front of each ear); and/or
  • swallowing difficulties.
Policy

NOTE:  CPT and HCPCS codes have been included in the coverage section as a guide only.  These codes may not be all inclusive, and coverage determination should be based on the description of the service.

NOTE:  Each benefit plan or contract defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply

NOTE:  The coverage section is organized on the basis of diagnostic procedures, non-surgical treatment, and surgical treatment for temporomandibular joint (TMJ) disorders (TMJD, also known as TMD).

Diagnostic Procedures

Blue Cross and Blue Shield of Montana (BCBSMT) may consider diagnostic procedures medically necessary when the patient has persistent symptoms of TMJD, including, but not limited to:

  • Pain localized in the TMJ, the muscles of mastication, and/or the periauricular area, which may or may not be aggravated by chewing, jaw function, and/or mandibular movement (such as yawning);
  • Noise in the TMJ with movement (e.g., clicking, grating, crepitus, and/or popping) that is accompanied by pain and/or decreased mobility, and is frequently audible by ear or can be heard with a stethoscope;
  • Headache, jaw ache, and/or facial pain, often in combination with neck, shoulder or back pain;
  • Limited and/or asymmetric mandibular movement;
  • Locking of the jaw;
  • Catching of the jaw on movement;
  • Point tenderness on TMJ palpation;
  • Signs of oral parafunction, such as bruxism (tooth grinding), e.g., abnormal occlusal wear.

For patients who meet the above criteria, the diagnostic procedures that BCBSMT may consider medically necessary to diagnose TMJ include:

  • Comprehensive physical examination with detailed history, which includes palpation of the myofascial muscles and jaw joint, measurements to assess any limitation of mouth opening, assessment of any noise in the jaw joint;
  • Transcranial and lateral skull x-rays, tomography, and arthrography (70100, 70110, 70260, 70140, 70150);
  • Computerized tomography (CT) or magnetic resonance imaging (MRI).  Generally, CT and MRI are only needed for pre-surgical evaluation (70336, 70486, 70487, 70488);
  • Cephalograms (70350);
  • Orthopantogram (70355);
  • Submentovertex x-rays (70250); and/or
  • Diagnostic arthroscopy, only if:
    1. Non-operative techniques have failed to adequately provide diagnostic information; AND
    2. The patient meets the criteria for surgery (listed below under Treatment—Surgical).

BCBSMT considers the following not medically necessary to diagnose TMJ disorders:

  • Routine blood studies and hormone studies;
  • Study models of the teeth

BCBSMT considers the following diagnostic procedures experimental, investigational, and unproven to diagnose TMJ disorders:

  • Electromyography (EMG), including dynamic surface EMG (95867, 95868);
  • Kinesiology;
  • Thermography (93760);
  • Neuromuscular junction testing (95937);
  • Somatosensory testing (95927);
  • Ultrasound imaging/sonogram;
  • 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 (other than testing included in the physician’s physical examination) (95831);
  • Range of motion measurements (other than measurements included in the physician’s physical examination) (95851);
  • Soft tissue x-rays of the neck (70360);
  • Bone and joint imaging (78300-78320);
  • Computerized joint sonography (77077);
  • Joint sounds analysis;
  • Joint survey;
  • Joint vibration analysis (77077);
  • Joint motion analysis (77077); and
  • Motion x-rays, digital motion x-rays (76496, 76120, 76125).

Treatment—Non-Surgical

BCBSMT may consider the following non-surgical treatments of TMJD medically necessary for patients who have persistent symptoms (see list under Diagnostic Procedures above) and have been diagnosed with TMJD:

  • Physical therapy; and/or
  • Injection of joint spaces with local anesthetics or corticosteroids; and/or.
  • Intra-oral reversible prosthetic devices and/or maxillomandibular (occlusal) appliances (encompassing fabrication, insertion, and adjustment); and/or
  • Study models of the teeth when done in preparation for a covered splint or appliance, or when needed as preparation for a covered surgical procedure.

The following non-surgical treatments are considered not medically necessary for treatment of TMJ disorders:

  • Facebow transfer;
  • Orthodontics;
  • Study models of the teeth when done in preparation for orthodontics;
  • Interdental fixation;
  • Dental restorations, dental prostheses;
  • Trigger point injections.

The following non-surgical treatments are considered experimental, investigational, and unproven for treatment of TMJ disorders:

  • Electrogalvanic stimulation (97014, 97032);
  • Iontophoresis (97033);
  • Biofeedback;
  • Ultrasound (97035);
  • Any methods used to alter the vertical dimensions and/or change the occlusal or jaw relationship, including orthodontic services (E1700, E1701, E1702);
  • Devices promoted to maintain joint range of motion and to develop muscles involved in jaw function;
  • Transcutaneous electrical nerve stimulation (TENS) (64550, 64553, 64555, 64560, 64565, 64573); and/or
  • Percutaneous electrical nerve stimulation (PENS) (64550, 64553, 64555, 64560, 64565, 64573).

Treatment—Surgical

Surgical procedures performed on the temporomandibular joint may be considered medically necessary for patients who have documented evidence of:

  • Severe trauma; OR
  • Pathological lesions of the TMJ; OR
  • History of failure to respond to non-surgical, conservative, reversible treatment modalities, usually on long-term, chronic basis; AND
    1. Continuous and/or repetitive episodes of pain and mechanical signs; AND/OR
    2. Significant clinical disability and/or loss in quality of life; AND/OR
    3. Evidence of progression of disease by history and/or imaging studies.

In addition, surgical procedures performed on the jaw (i.e., orthognathic surgery) may be considered medically necessary when:

  • The patient has met the above criteria; AND
  • Documentation is provided that proves a positive relationship between the patient’s long-term symptoms and a malocclusion and/or discrepancy in jaw alignment.

Surgical procedures that may be performed for treatment of TMJ in situations that have met the above criteria include, but are not limited to:

  • Orthognathic surgery, including, but not limited to:
    1. LeFort I, midface reconstruction (21141, 21142, 21143, 21145, 21146, 21147);
    2. Mandibular reconstruction, with or without bone graft and/or internal rigid fixation; segmental osteotomy (21193, 21194, 21195, 21196, 21198, 21199).
  • Arthrocentesis;
  • Injections of the joint other than arthrocentesis;
  • Manipulation for reduction of fracture or dislocation, with documentation and/or confirmation of dislocation or fracture  (NOTE:  This does NOT include periodic manipulation or adjustments that are done routinely with splint therapy);
  • Arthroscopic procedures, including, but not limited to:
    1. Arthrocentesis;
    2. Arthrolysis;
    3. Debridement;
    4. Disc manipulation/repositioning/fixation/release;
    5. Abrasion arthroplasty; or
  • Open surgical procedures including but not limited to:
    1. Disc arthroplasty (repositioning, recontouring, fixation discopexy);
    2. Condylectomy;
    3. Meniscectomy (disc removal) without replacement, temporary alloplastic implant, or reconstruction with autogenous tissue graft;
    4. Osseous recontouring (mandibular condyle, glenoid fossa, articular eminence);
    5. Arthroplasty for ankylosis;
    6. Joint reconstruction, with autogenous costochondral graft or prosthesis;
    7. Open reduction, internal fixation of condylar fracture/dislocation;
    8. Excision of tumor or bony hypertrophy/hyperplasia;
    9. Mandibular/condylar repositioning (condylotomy and/or osteotomy);
    10. Coronoidectomy, mandibular coronoidectomy;
    11. Myotomy.

Genioplasty, with or without sliding osteotomy, is considered cosmetic (21120, 21121, 21122, 21123).

Rationale

No clear consensus has emerged regarding the definition, cause, diagnosis, or treatment of TMJD.  In 1996, the National Institutes of Health (NIH) convened a 15-member, non-federal, expert panel for a technology assessment conference on management of TMJD.  The panel concluded that no treatment for TMJD demonstrated effectiveness and that invasive interventions warranted caution, particularly surgery that permanently alters the tooth structure or jaw position. The panel also recommended that noninvasive therapies are preferred for the vast majority of patients, and that surgical intervention may be warranted only for a small percentage of patients with chronic and substantial dysfunction for whom noninvasive therapies have failed. 

In 2001, the Agency for Healthcare Research and Quality (AHRQ) contracted with the Lewin Group to conduct a study of the effectiveness and the per-patient cost of treatment for TMJD, based on review of evidence published between 1996 and 2001.  Their findings reinforce previous conclusions that few randomized clinical trials (RCTs) or other types of rigorous studies exist for determining the effectiveness of treatments for TMJD; published reports of clinical research on TMJD consist primarily of non-randomized uncontrolled trials, case series, and anecdotal descriptions of treatment techniques.

Various factors affect the body of evidence on TMJD treatment.  There is no consensus regarding the biological cause or etiology of TMJD; clinicians and scientists believe that multiple unrelated, underlying diseases can cause TMJD symptoms, and patients may have more than one condition concurrently.  Also, risk factors are poorly documented and understood.  Knowledge regarding the natural course of the disease is limited and controversial; symptoms can increase or abate over time, and can resolve spontaneously, leading to insufficient long-term longitudinal studies.  This makes it difficult to demonstrate the net effect of TMJD interventions, especially in the absence of RCTs.  For example, in a prospective cohort study, Kurita et al. showed that approximately 76% of patients with disc displacement without reduction became either asymptomatic or improved within 2.5 years.  Barkin and Weinberg concluded that the signs and symptoms of anterior disc displacement without reduction tend to be alleviated during the natural course of the condition, and progression of TMJD was not established; they encouraged a conservative and reversible approach to treatment. 

Because of the wide range of signs and symptoms and inconsistent information about TMJD, there are no clear diagnostic criteria that are widely accepted and integrated into clinical practice. According to the National Institute of Dental and Craniofacial Research (NIDCR) in 2000, the patient’s description of symptoms, combined with a simple physical examination of the face and jaw, provides information useful in diagnosing these disorders in about 90% of cases. 

Many types of healthcare providers may be involved in the management of TMJD, and treatment selection appears to be associated with the type of provider.  Lack of a well-recognized or uniform set of outcome measures used for evaluating TMJD interventions diminishes the ability to integrate findings and compare results of multiple studies.  All of these factors present challenges to determining treatment effectiveness. 

Four RCTs address behavior modification and physical therapy in treating TMJD symptoms.  These studies suggest that some methods of behavior modification and physical therapy may be useful in the short term treatment of TMJD symptoms; further studies are needed to show these modalities are more useful than non-intervention in the long-term.

Four RCTs investigated the effectiveness of non-surgical occlusal adjustment therapies for treatment of TMJD, with mixed results in improving TMJD pain and functioning.  Davies and Gray conducted two studies with different types of splints, different durations or timing of splint use, and no untreated control group.  In both of these short-term studies all groups improved relative to baseline.  Eckberg et al. found both the stabilization-appliance and control-appliance groups had improved, though the treatment group experienced significant reduction in pain and functioning relative to the control group.  Magnusson and Syren conducted a six-month study of patients using an interocclusal appliance, physical therapy, or combination therapy, and found improvements in each therapy group, though statistical differences were not assessed due to small sample sizes.  Overall, occlusal therapy had positive outcomes in the short term, though splints did not emerge as being clearly superior to control groups receiving no therapy.

Three RCTs address the efficacy of surgical techniques to diminish TMJD.  All three are focused specifically on arthroscopy and/or arthrocentesis, and none included a non-surgical group or a non-treatment group; the authors failed to detect a statistically significant difference between the two treatment groups.  Goudot et al. found a statistically significant difference between treatment groups in improving function, though not in relief of pain, and they concluded that arthroscopy provides better results than arthrocentesis for functional treatment. 

In terms of evidence-based healthcare, evidence on TMJD remains largely weak and unfocused, which contributes to ambiguity and variation in patient care for TMJD.  The Lewin study concluded that overall the body of evidence on the effectiveness of TMJD treatment is limited and lacking in rigor; particularly lacking were studies with sufficient power and patient follow-up to detect any true differences in effectiveness among alternative treatments.  A Medline search for clinical trials and studies between 2001 and 2005 failed to identify any new studies that would change the conclusions reached by the 1996 NIH and the 2001 AHRQ reports.

Coding

NOTE:  Many non-TMJD ICD-9 diagnosis codes are frequently used when billing for treatment of TMJD in addition to or in lieu of the TMJD diagnosis.

NOTE:  CPT and HCPCS codes have been included in the text of this policy as a guide.  These codes may not be all inclusive, and claim reviewers should evaluate the description of the service provided, regardless of the codes billed. 

Claims for diagnosis and treatment of TMJD are not always easily identified as such.   For example, professional designation of the provider can indicate that the claim is for TMJD, i.e., the only joint that can be treated under a dental license is the temporomandibular joint.  In addition, the following list is provided as an aid in identifying TMJD claims.  This list includes but is not limited to the codes that might be submitted for TMJD:

Splints:

21076, Impression and custom preparation of splint; 21085, Oral surgical splint; 21089, Unlisted maxillofacial prosthetic procedure; 21110, Application of interdental fixation;

97703, Checkout for orthotic; 97520, Prosthetic training; 97535, Self-care/home management training

TMJ Radiographs:

70100, Mandible; 70140 , Facial Bones; 70220, Sinuses; 70250,Skull; 70328, TMJ; 70330, TMJ; 70332, TMJ; 70336, TMJ, MRI; 70350, Cephalometric; 70355, Orthopantogram; 70360, Neck—soft tissue; 76100, Tomography; 76101, Tomography; 76102 – Tomography

Tests, Exams:

95831, Muscle Testing; 95851, Range of Motion study

CODING:

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

ICD-9 Codes

Refer to the ICD-9-CM manual

ICD-10 Codes

Refer to the ICD-9-CM manual

Procedural Codes: 20550, 20605, 21010, 21050, 21060, 21070, 21073, 21076, 21081, 21085, 21089, 21110, 21116, 21120, 21121, 21122, 21123, 21141, 21142, 21143, 21145, 21146, 21147, 21193, 21194, 21195, 21196, 21198, 21199, 21240, 21242, 21243, 21480, 21485, 21490, 29800, 29804, 64550, 64553, 64555, 64565, 70100, 70110, 70140, 70150, 70220, 70250, 70260, 70300, 70310, 70320, 70328, 70330, 70332, 70336, 70350, 70355, 70360, 70486, 70487, 70488, 76100, 76101, 76102, 76120, 76125, 76496, 76999, 77077, 78300, 78305, 78306, 78315, 78320, 95831, 95851, 95867, 95868, 95927, 95937, 97010, 97014, 97024, 97026, 97032, 97033, 97035, 97140, 97520, 97530, 97535, 98925, 98943, E1700, E1701, E1702, E0746, S8262, [Deleted 1/2011: 64573], [Deleted 1/2012: 64560]
References
  1. Okeson, Jeffrey P., DMD.  Orofacial Pain—Guidelines for Assessment, Diagnosis, and Management.  Chicago: Quintessence Publishing Company, Inc.  (1996): 113-184.
  2. Davies S. and R. Gray.  The pattern of splint usage in the management of two common temporomandibular disorders. Part I: The anterior repositioning splint in the treatment of disc displacement with reduction.  British Dental Journal (1997 Sep 27) 183(6):199-203.
  3. Davies S. and R. Gray.  The pattern of splint usage in the management of two common temporomandibular disorders. Part II: The stabilisation splint in the treatment of pain dysfunction syndrome.  British Dental Journal (1997 Oct 11) 183(7):247-51.
  4. Ekberg E., et al.  Occlusal appliance therapy in patients with temporomandibular disorders. A double-blind controlled study in a short-term perspective.  ACTA Odontologica Scandinavica (1998 Apr) 56(2):122-8.
  5. Kurita K., et al.  Natural course of untreated symptomatic temporomandibular joint disc displacement without reduction.  Journal of Dental Research.  (1998 Feb) 77(2):361-5.
  6. Magnusson T. and M. Syren.  Therapeutic jaw exercises and interocclusal appliance therapy. A comparison between two common treatments of temporomandibular disorders.  Swedish Dental Journal.  (1999) 23(1):27-37.
  7. Temporomandibular Joint Disorders Interagency Working Group (TMJDIWG), research Agenda/Plan 2000.  http://www.nider.nih.gov  Accessed July, 2005. 
  8. Barkin S. and S. Weinberg.  Internal derangements of the temporomandibular joint: the role of arthroscopic surgery and arthrocentesis.  Journal Canadian Dental Association.  (2000 Apr) 66(4):199-203.
  9. Goudot P., et al.  Improvement of pain and function after arthroscopy and arthrocentesis of the temporomandibular joint: a comparative study.  Journal Craniomaxillofacial Surgery.  (2000 Feb) 28(1):39-43.
  10. Study of the per-patient cost and efficacy of treatment for temporomandibular joint disorders.  Contract No.:290-96-0009.  Prepared for the Agency for Healthcare Research and Quality.  Prepared by The Lewin Group.  April 30, 2001.  http://www.tmj.org/archive.asp Accessed July, 2005.
  11. Temporomandibular Joint Dysfunction.  Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2003 January) Medicine 2.01.21.
  12. TMJ Diseases and Disorders.  The TMJ Association, LTD.  http://tmj.org Accessed July, 2005.
  13. American Academy of Orofacial Pain—TMD Tutorial.  http://aaop.med-office.com Accessed June, 2005.
History
March 2011  Added investigational surgical, diagnositc, nonsurgical treatments. Added rationale and references. 
 April 2013  Policy formatting and language revised.  Policy title changed from "Temporomandibular Joint Dysfunction (TMD)" to "Temporomandibular Joint (TMJ) Disorders (TMJD)".
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Temporomandibular Joint (TMJ) Disorders (TMJD)