Temporomandibular Disorder (TMD) may be the result of congenital and developmental anomalies; fractures and dislocations resulting from trauma, internal derangement, disc displacements, or ankylosis (stiffening or fixation of a joint); or arthritic and neoplastic diseases. Symptoms attributed to TMD are varied and include, but are not limited to, clicking and popping sounds in the jaw; headaches; close or open locking of the jaw due to muscle spasms (trismus) or displaced disc; pain in the jaw, ears, neck, arms, and spine; and tinnitus.
According to the National Institute of Dental and Craniofacial Research, experts strongly recommend initial use of the most conservative, reversible treatments when possible. Such treatments do not invade the tissues of the face, jaw, or joint, or cause permanent changes in the structure or position of the jaw or teeth.
Definitions:
A qualified dentist is trained and experienced in the overall care of oral health, the temporomandibular joint, dental occlusion and associated orofacial structures; and is a Doctor of Dental Surgery (DDS) or Doctor of Dental Medicine (DMD).
NOTE:
Criteria for All Treatments
I. Treatment of temporomandibular disorder (TMD) may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following diagnostic criteria are met, and criteria for specific treatments listed in sections II and III are met:
Non-Surgical Treatments
II. The following non-surgical treatments may be considered MEDICALLY NECESSARY AND APPROPRIATE in the treatment of temporomandibular disorder when the diagnostic criteria in section I have been met::
Surgical Treatments
III. The following surgical treatments may be considered MEDICALLY NECESSARY AND APPROPRIATE in the treatment of temporomandibular disorder when the diagnostic criteria in section I have been met:
Experimental / Investigative Treatments
IV. The following non-surgical treatments of temporomandibular disorder are considered EXPERIMENTAL/INVESTIGATIVE due to the lack of clinical evidence demonstrating an impact on improved health outcomes:
V. Arthroscopy of the temporomandibular joint solely for diagnostic purposes is considered EXPERIMENTAL/INVESTIGATIVE due to the lack of clinical evidence demonstrating an impact on improved health outcomes.
Documentation Submission:
Documentation supporting the medical necessity criteria described in the policy must be included in the prior authorization, when prior authorization is required. In addition, the following documentation must also be submitted:
Coverage
The following medical and surgical treatments are generally excluded from medical coverage under the member benefit document:
No additional statements.
Summary of Evidence
Temporomandibular disorder (TMD) is characterized by pain in the temporomandibular joint (TMJ) and surrounding tissues. Initial conservative therapy is generally recommended, however there are also a variety of nonsurgical and surgical treatment options for individuals whose symptoms persist. Diagnostic criteria that closely align with professional society guidelines have been developed to ensure that the diagnosis of TMD is appropriately assigned prior to treatment for the disorder. In addition, medical necessity criteria have been developed for both nonsurgical and surgical treatments for TMD that closely align with professional society guidelines.
Rationale
Temporomandibular disorders (TMDs) are a group of orofacial pain conditions which are the most common non-dental pain complaint in the maxillofacial region. It has been estimated that the disorder may affect between 5-25% of adults. Diagnosis and management of TMD can be challenging as the condition comprises a broad range of symptoms that vary in intensity. While clinical examination is considered the most important process in the diagnosis of TMD, imaging also serves as a valuable adjunct. Depending on the type of TMD, many treatment modalities have been proposed, ranging from conservative options to open surgical procedures.
Since 1981, several muscle-monitoring devices have been cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process. Some examples are the K6-I Diagnostic System (Myotronics), the BioEMG III™ (Bio-Research Associates), M-Scan™ (Bio-Research Associates), and the GrindCare Measure (Medotech A/S). These devices aid clinicians in the analysis of joint sound, vibrations, and muscle contractions when diagnosing and evaluating TMD.
Schiffman et al (2014) published diagnostic criteria for temporomandibular disorders for clinical and research applications. In this publication, the authors stated, “diagnostic criteria for TMD with simple, clear, reliable, and valid operational definitions for the history, examination, and imaging procedures are needed to render physical diagnoses in both clinical and research settings.”
The 2001 American Society of Temporomandibular Joint Surgeons (ASTMJS) guideline for diagnosis and management of disorders involving the temporomandibular joint (TMJ) outlines clinical presentation of TMD, focusing on disc displacement, internal derangement, and coexisting osteoarthritis. Typical signs and symptoms include pain in the jaw joint, headaches, and radiating pain from the jaw joint to the temple, ears, side of neck, and upper shoulder. The pain is usually aggravated by wide opening and chewing. There is often clicking, popping, or locking of the jaw due to disc interference. Incisal opening, protrusion, and contralateral movements are generally decreased and may interfere with chewing. In addition, the jaw joint and muscles are often tender to palpation. A history of changing occlusion and/or asymmetry may also be signs of TMD. For diagnosis of TMD, the guideline states that a detailed history and general physical examination are essential. As part of evaluation and diagnosis, imaging of the TMJs and associated structures is necessary to establish the presence or absence of pathology and stage of disease in order to select the appropriate treatment and also assist in prognosis. Basic screening radiographs include panoramic films and tomograms, and more advanced diagnostic imaging can include CT, 3-D CT, and MRI. The guideline recommends conservative treatment first for mild or moderate pain and dysfunction associated with TMD. This includes simple pharmacologic agents, such as NSAIDs, low dose tricyclics, and muscle relaxants. The guideline recommends nonsurgical treatment as first-line therapy for all symptomatic patients with TMDs. Recommended nonsurgical treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs), maxillomandibular intraoral appliances, physical therapy, and behavior modification. The guideline states that surgical procedures considered accepted and effective for patients with TMDs associated with internal derangement or osteoarthritis include arthroscopy, arthrocentesis, condylotomy, and arthrotomy.
In 2017 and 2023, the American Association of Oral and Maxillofacial Surgeons (AAOMS) published clinical practice guidelines for oral and maxillofacial surgery related to TMD. The guidelines state that clinical presentation includes jaw joint and muscle pain, referred facial pain, pain with chewing, restricted range of jaw motion (e.g., locking of the jaw joint), joint noises (e.g., clicking, popping) associated with pain, and abnormal chewing function. The pretreatment assessment should include a general history and physical examination, as well as a focused history and examination of the TMJ region. An imaging examination is also recommended and may include, but is not limited to, panoramic radiography, cephalometric radiography, conventional tomography, CT, cone-beam CT (i.e., 3-D CT), and/or MRI. Pretreatment therapeutic goals are determined individually for each patient. Conservative management includes medications, such as NSAIDs, simple analgesics, and muscle relaxants. Regarding surgical treatment, the guidelines state that TMJ surgery is indicated for the treatment of a wide range of pathologic conditions, including developmental and acquired deformities, internal derangements, functional abnormalities, and degenerative joint disease. Surgical intervention is indicated only when nonsurgical therapy has been ineffective and pain and/or dysfunction are moderate to severe. Surgery is not indicated for asymptomatic or minimally symptomatic patients. Surgery also is not indicated for preventive reasons in patients without pain and with satisfactory function. Recommended surgical management includes manipulation, arthrocentesis, arthroscopic surgery, arthrotomy/arthroplasty (including discectomy with or without replacement), and mandibular condylotomy/condylectomy (with or without replacement).
In 2015, the American Association for Dental, Oral, and Craniofacial Research (AADOCR) reaffirmed their policy statement regarding TMJ. In this statement, it is recommended that the differential diagnosis of TMDs or related orofacial pain conditions should be based primarily on information obtained from the patient’s history, clinical examination, and TMJ radiology or other imaging procedures. The choice of adjunctive diagnostic procedures should be based upon published, peer-reviewed data showing diagnostic efficacy and safety. However, the consensus of recent scientific literature about currently available technological diagnostic devices for TMDs is that except for various imaging modalities, none of them shows the sensitivity and specificity required to separate normal subjects from TMD patients or to distinguish among TMD subgroups.
According to the National Institute of Dental and Craniofacial Research, experts strongly recommend using the most conservative and reversible treatments possible for TMDs. Conservative treatments do not invade the tissues of the face, jaw, or joint, or involve surgery. Reversible treatments do not cause permanent changes in the structure or position of the jaw or teeth. Even when TMJ disorders have become persistent, most patients still do not need aggressive types of treatment. Because the most common jaw joint and muscle problems are temporary and do not get worse, simple treatment may be all that is necessary to relieve discomfort. Short term use of over-the-counter pain medicines or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen; the use of a stabilization splint, or bite guard, that fits over upper or lower teeth may also provide relief. If a stabilization splint is recommended, it should be used for a short time and should not cause permanent changes in bite. Physical therapy is a nonsurgical treatment option, and the goal is to maintain, improve, or bring back movement and physical function. There are several types of physical therapy, one being manual therapy, in which a therapist uses manipulation techniques with their hands to stretch the soft tissues and muscles around the joint. Manual therapy has been shown to help improve function and relieve pain associated with TMDs. In addition, certain behavioral health approaches, usually offered by a psychologist, have been shown to help manage TMDs. These include cognitive behavioral therapy, which seeks to identify negative thoughts or thought patterns and change them, as well as provide coping skills. Prolotherapy involves injecting a solution into the TMJ area that causes irritation, with the goal of triggering the body to respond by repairing the joint. Prolotherapy has shown promise specifically for TMDs in which the joint is out of its normal position (dislocation) or when the joint goes beyond its normal range of movement (hypermobility), however published clinical evidence is limited on this treatment for TMDs. Surgical treatments are more complex and should be avoided when possible. Arthroscopy is a treatment that can remove adhesions or reposition the joint’s disc, which works moderately well in helping improve pain and function. Arthrocentesis is a procedure where liquid is inserted into the TMJ and the pressure caused by the liquid removes scar-like tissue (adhesions). In addition, when the liquid is flushed out of the joint, it removes substances that cause inflammation. Arthrocentesis has been shown to help with pain relief and improve mouth opening in people whose temporomandibular disc is out of place.
Reference List
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Acknowledgements:
CPT® codes copyright American Medical Association® 2023. All rights reserved.
CDT codes copyright American Dental Association® 2023. All rights reserved.
