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.
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:
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
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
95831, Muscle Testing; 95851, Range of Motion study
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.