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Medical and Surgical Treatment of Temporomandibular Joint Disorder
07.08.03i

Policy

MEDICALLY NECESSARY

Medical and/or surgical treatment for temporomandibular joint disorder (TMD), also known as temporomandibular joint syndrome (TMJS) or craniomandibular disorder (CMD), is considered medically necessary and, therefore, covered for the following treatment modalities when a benefit for the service exists and when the medical necessity criteria described below are met.

MEDICAL TREATMENT
The following medical treatments for the treatment of TMD are considered medically necessary:
  • ​Physical therapy (e.g., jaw exercises, thermal modalities, massage, muscle stretching, correction of body posture, prosthetic therapy, and relaxation/stress-reduction techniques)​
  • Biofeedback
    • When a functional deficit is present, biofeedback is covered up to two to three visits per week for 6 to 8 weeks. Sessions provided beyond this are considered not medically necessary, and, therefore, not covered.
    • The individual's medical records must document an ongoing treatment plan, which includes the following:
      • Diagnosis
      • Frequency goals
      • Patient instruction (e.g., practice and follow-through)
      • Frequency of treatment (e.g., two times per week)
  • Trigger point injections when at least one of the following criteria is met:
    • Noninvasive medical management is unsuccessful
    • Joint movement is mechanically blocked
    • As a bridging therapy to relieve pain while other treatments are being initiated, such as physical therapy or medication or as a single therapeutic maneuver
  • Intra-articular injections with local anesthetics or corticosteroids
Comprehensive medical management of TMD includes the treatment modalities outlined above. Unless contraindicated, it is expected that the individual has had a trial of at least one treatment modality before the individual is considered refractory to treatment.

SURGICAL TREATMENT
Surgical treatments of TMD are considered medically necessary when all of the following criteria are met:
  • The individual is refractory to at least one of the medical (i.e., nonsurgical) therapies
  • The individual has clinically significant pain localized to the joint and has worsening pain during jaw function (e.g., chewing, talking)
  • The individual has evidence of mandibular malfunction (e.g., insufficient interincisal mouth opening for routine dental care)
  • The individual has radiologic confirmation of joint pathology (e.g., MRI, CT)*
The following surgical treatments for the treatment of TMD are considered medically necessary:
  • Arthrocentesis (*radiologic confirmation of joint pathology is not required for arthrocentesis)
  • Arthroscopy
  • Arthrotomy/arthroplasty
    • Indicated for individuals who have TMJ internal derangement and osteoarthrosis and have failed to respond to simpler surgical procedures or failed previous open surgery
  • Condylectomy
  • Condylotomy
  • TMJ cartilaginous disc repair or removal with or without replacement
  • TMJ reconstruction with autogenous graft, allogeneic graft, or a US Food and Drug Administration (FDA)-approved alloplastic implant
    • Indicated for adult individuals who have disarticulation due to trauma, joint degeneration, or destruction due to advanced degenerative joint disease, ankylosis, tumor, or complications of previously performed open surgery
PROCEDURES THAT ALTER VERTICAL DIMENSION
When not a benefit contract exclusion, the following treatments​ of TMD used to alter vertical dimension may be considered medically necessary and therefore covered. Individual benefits must be verifed.
  • Reversable intraoral appliances (e.g., occlusal splints, bite plates)
  • Systemic occlusal adjustment​
EXPERIMENTAL/INVESTIGATIONAL

All other medical and surgical treatments of TMD are considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of these services cannot be established by review of the available published peer-reviewed literature. These include, but are not limited to, the following treatments:
  • Hyaluronic acid injections
  • Botulinum toxin injections
  • Ketamine injections (intra-articular, intramuscular)
  • Acupuncture/dry needling
  • Electrical modalities including but not limited to: transcutaneous electrical nerve stimulation (TENS), percutaneous electrical nerve stimulation (PENS), electrogalvanic stimulation, and iontophoresis
  • Laser treatment
  • Occlusal adjustment and repositioning splints that permanently change the bite
  • Orofacial myofunctional therapy
  • Orthognathic surgery
  • Treatments that cause permanent changes in the bite or jaw, including crown or bridge work
  • Ultrasound treatment
  • Prolotherapy
REQUIRED DOCUMENTATION​

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.​

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, medical and/or surgical treatment for temporomandibular joint disorder (TMD), also referred to as temporomandibular joint syndrome (TMJS) or craniomandibular disorder (CMD), is covered under the medical benefits of the Company's products when a benefit exists for the applicable service and when any respective medical necessity criteria listed in this medical policy are met. Individual benefits must be verified.

Services that are identified in this policy as experimental/investigational are not eligible for coverage or reimbursement by the Company.

Services that are experimental/investigational are a benefit contract exclusion for all products of the Company.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

There are numerous products and devices approved by the FDA for medical and surgical treatment of TMD.

FDA-approved total and partial alloplastic prostheses including, but not limited to, the following are noted below with their FDA-approved indications and contraindications.

Patient-Fitted Temporomandibular (TMJ) Reconstruction Prosthesis (TMJ Concepts, Ventura, CA) is a prosthesis fitted to the patient using a model produced from a computed tomography (CT) scan. The device is FDA-approved for reconstruction of the TMJ for the following indications:
  • Inflammatory arthritis involving TMD not responsive to other modalities of treatment
  • Recurrent fibrous and/or bony ankylosis not responsive to other modalities of treatment
  • Failed tissue graft
  • Failed alloplastic joint reconstruction
  • Loss of vertical mandibular height and/or occlusal relationship due to bone resorption, trauma, developmental abnormality, or pathologic lesion
Contraindications:
  • Active or suspected infections in or about the implantation site
  • Uncontrollable masticatory muscle hyperfunction (clenching or grinding), which may lead to overload and loosening of screws
  • Known allergy to any of the component materials
TMJ Fossa Eminence and Condylar Prosthesis (TMJ Fossa-Eminence/Condylar Prosthesis System™,TMJ Medical, Golden, CO) is a metal-on-metal prosthesis. The total joint replacement system is available in sizes to which the tissues are adapted to fit the prosthesis. The device is intended for use in treatment of severe TMD due to:
  • Inflammatory arthritis involving the TMJ not responsive to other modalities of treatment
  • Recurrent fibrous and/or bony ankylosis not responsive to other modalities of treatment
  • Failed tissue graft
  • Failed alloplastic joint reconstruction
  • Loss of vertical mandibular height and/or occlusal relationship due to bone resorption, trauma, developmental abnormality, or pathologic lesion
Contraindications:
  • Infection or malignancy in the head or neck region
  • Known allergy to any of the components of the system
  • Ability to exert significant postoperative masticatory muscle hyperfunction (clenching or grinding), which may lead to overload and fracture of the device or loosening of the screws
An additional warning appears in the labeling of this device as follows:
    Dynamic fatigue tests were conducted on the TMJ Medical Metal-on-Metal Total Joint Replacement System with a force applied vertically to the device. No failures occurred at 130 lbs. Physicians should carefully consider the results of these fatigue tests when patients present with particular anatomical considerations or unusual forces.
Partial TMJ Prosthesis (TMJ Fossa-Eminence Prosthesis,™ TMJ Medical, Golden, CO) is intended for use in the treatment of severe TMJ disease due to:
  • Inflammatory arthritis involving the TMJ not responsive to other modalities of treatment
  • Recurrent fibrous and/or bony ankylosis not responsive to other modalities of treatment
  • Failed tissue graft
  • Failed alloplastic joint reconstruction
  • Internal derangement confirmed to be pathological in origin by both clinical observation and radiographic findings where the patient has moderate to severe pain and/or disabling dysfunction and has not responded to less invasive, conventional therapy
Contraindications:
  • Infection or malignancy in the head or neck region
  • Known allergy to any of the components of the system
  • Ability to exert significant postoperative masticatory muscle hyperfunction (clenching or grinding), which may lead to overload and fracture of the device or loosening of the screws
Use of the Fossa-Eminence alone for internal derangement carries an FDA warning included in the product labeling stating that the medical literature reports the following:
  • Many cases of internal derangement resolve after nonsurgical treatment, or in some cases with no treatment at all
  • The complexity of contributing factors in this patient population must be considered in the diagnosis and decision to surgically treat patients​
  • Replacement surgery should be utilized only as a last resort after other treatment options are exhausted or determined not to be warranted in the medical judgment of the physician/dentist in consultation with the patient
  • The Wilkes classification is a guide in determining the severity of the disease. This classification should not be relied on as a sole criterion for surgical treatment.
  • The long-term effects of the TMJ Fossa-Eminence Prosthesis System on the natural mandibular condyle are unknown. Remodeling of the natural mandibular condyle has been observed. Other degenerative changes may be attributable to the TMJ Fossa-Eminence Prosthesis. Therefore, the physician/dentist should periodically monitor the condition of the natural mandibular condyle.
Total Temporomandibular Joint Replacement System (Walter Lorenz Surgical Inc., Jacksonville, FL), composed of cobalt-chromium-molybdenum (Co-Cr-Mo) alloy with titanium alloy coating, is indicated for reconstruction of the TMJ for the following diagnoses:
  • Arthritic conditions (osteoarthritis, traumatic arthritis, rheumatoid arthritis)
  • Ankylosis
  • Revision procedures due to failed alloplastic or autogenous grafts
  • Avascular necrosis
  • Multiply-operated joints
  • Fracture
  • Functional deformity
  • Posttumor excision of benign or malignant neoplasms
Contraindications:
  • Active or chronic infection
  • Patient conditions where there is insufficient quantity or quality of bone to support components
  • Systemic disease with increased susceptibility to infection
  • Patients with extensive perforations in the mandibular fossa and/or bony deficiencies in the articular eminence or zygomatic arch that would severely compromise support for the artificial fossa component
  • Partial TMJ joint reconstruction
  • Known allergic reaction to any materials used in the components
  • Patients with mental or neurological conditions who are unwilling or unable to follow postoperative care instructions
  • Skeletally immature patients
  • Patients with severe hyperfunctional habits (e.g., clenching, grinding)
  • Patients with foreign body reactions due to previous implants

Description

The temporomandibular joint (TMJ) connects the temporal bone of the skull with the mandible (i.e., lower jaw) by an articulating condyloid process that moves within the glenoid fossa. The joint is cushioned by a layer of cartilage and a disc that lies between the articulating surfaces. The disc adds stability and acts as a shock absorber. The TMJ is affected by the same conditions found in other joints in the body, including traumatic injuries, internal derangement, dislocations, ankylosis, arthritis, neoplasms, and congenital and developmental abnormalities.

TEMPOROMANDIBULAR JOINT DISORDER

Temporomandibular joint disorder (TMD), also referred to as temporomandibular joint syndrome (TMJS) or craniomandibular disorder (CMD), is an all-inclusive term used to describe disorders of the muscles of mastication often referred to as myofascial pain dysfunction (MPD) and true image-validated abnormalities of the joint. TMD is a heterogeneous grouping without a standard etiology; it is identified by common signs and symptoms that include complaints of pain in the face or jaw area, headaches, earaches, dizziness, masticatory musculature hypertrophy, limited mouth opening, closed or open lock of the TMJ, abnormal occlusal wear, and clicking or popping sounds in the joint.

Because of the lack of understanding regarding the etiology and course of the condition, many types of professional providers may see patients with TMD. Therefore, treatment approaches are frequently dependant on the specialty of the treating practitioner.

TMD is characterized by pain in the TMJ or its adjacent tissues, functional limitations of the mandible, or clicking in the TMJ during motion. TMJ disorders are common and often self-limiting, with up to 75% of adults having at least one sign of joint dysfunction.

The American Society of Temporomandibular Joint Surgeons notes that TMD is a collective term that encompasses all problems related to the TMJ and its related musculoskeletal structures. Disc displacement frequently is a result of an internal derangement in addition to a coexisting osteoarthritis or degenerative joint disease, which is the most common cause of persistent TMJ pain and joint dysfunction requiring a surgical intervention.

MEDICAL TREATMENT OF TMD

Few conclusive studies are available on the safety and effectiveness of TMD treatments. However, the available published peer-reviewed literature indicates that conservative management should be the initial approach. Self-care practices (e.g., eating soft food, learning stress reduction techniques, and practicing jaw exercises), pharmacological therapy (e.g., analgesics and/or nonsteroidal anti-inflammatory drugs [NSAIDs]), physical therapy (e.g., exercises, thermal modalities, massage, muscle stretching, correction of body posture, and relaxation techniques), or intraoral appliances (e.g., occlusal splints, bite plates) are all reversible treatments that are considered first-line management. According to the TMJ Association and the National Institutes of Health, treatments that cause permanent changes in the bite or jaw should be avoided, including crown and bridge work and occlusal adjustment and repositioning splints that permanently change the bite. A Cochrane literature review found insufficient data to support active orthodontic treatment for TMD.

Psychological counseling, behavioral therapy, and techniques such as biofeedback and relaxation therapy are conservative management options. Studies indicate that individuals who do not respond to a bite appliance may respond to therapy such as electromyographic biofeedback or conditioned relaxation. Biofeedback uses electronic monitors such as electroencephalography, electromyography, and cutaneous thermometers and pulse oximeters to teach individuals how to consciously control physiologic functions such as respiratory rate, heart rate, skin temperature, and blood pressure. Biofeedback has been shown to be effective in managing stress-related disorders, pain, and the treatment of TMD.

ACUPUNCTURE
As defined by the American Association of Acupuncture and Oriental Medicine, acupuncture is the stimulation of anatomical locations in the body, alone and in combination, to treat disease, injury, pain, and dysfunction. Needles may be used to provide invasive stimulation of these locations. The available published peer-reviewed literature indicates that acupuncture as a treatment of TMD remains controversial.

Peer-Reviewed Literature

In a systematic review, Jung et al. (2011) evaluated the available peer-reviewed literature to determine the safety and effectiveness of acupuncture and acupuncture-like therapies as treatments for TMD. Seven randomized controlled trials (RCTs) met the inclusion criteria and represented a total of 141 individuals. The sample size of the included studies ranged from seven to 28. Four studies used a single acupuncture session, while the other three used six to 12 sessions. All seven studies reported visual analog scale (VAS) pain scores as an outcome measurement. A pooled analysis from five studies (n=107) found a statistically significant improvement in pain intensity. A pooled analysis from two studies (n=18) did not find a statistically significant difference in effectiveness between acupuncture and a penetrating sham procedure. The authors concluded that the evidence for acupuncture as a symptomatic treatment of TMD was limited, primarily because of the small number of studies and small sample sizes. Additionally, most studies assessed the effectiveness of acupuncture as a treatment of TMD only immediately posttreatment.

TRIGGER POINT INJECTIONS AND DRY NEEDLING
Trigger point injection (TPI) is a procedure used to treat painful areas of muscle that are knotted and do not relax, also known as trigger points. Trigger points may irritate the nerves around them and cause pain that is felt in other parts of the body. During TPI, a small needle is inserted into the individual's trigger point. The injection typically contains a local anesthetic or corticosteroid. With the injection, the trigger point is made inactive and the pain is alleviated.

Dry needling is a variant of TPI therapy that uses only needles to stimulate trigger points and alleviate pain; no medications are injected into the affected area. Dry needling is different from acupuncture because acupuncture stimulates distant points or meridians. TPIs are clinically accepted treatments for myofascial pain disorder. The available published peer-reviewed literature indicates that the evidence is inconclusive regarding the effectiveness of dry needling for myofascial pain disorder.

Peer-Reviewed Literature

In a systematic review and meta-analysis, Clécio et al. (2019) reviewed the effects of dry needling on orofacial pain of myofascial origin in individuals with TMJ dysfunction. The authors concluded that dry needling is better than sham therapy for pressure pain threshold (PPT) and better than other interventions for pain intensity in the short term. However, due to the low quality of evidence, dry needling cannot be recommended over sham therapy or other interventions. There are insufficient data to draw conclusions about dry needling for the treatment of orofacial pain associated with TMD. Further RCTs are needed.

In a quasi-experimental study consisting of 15 individuals with a diagnosis of a minimum level II severity TMD, Neto et al. (2019) investigated the effect of the physiotherapy technique using manual myofascial therapy and dry needling. Individuals were randomly assigned to two groups: group one received myofascial manual therapy and group two received dry needling treatment. The authors concluded that myofascial therapy and dry needling focused on the masseter and temporal, promoting an increase in the PPT values and a decrease in the pain intensity values (VAS) after a single session on temporomandibular symptoms. However, further studies with larger samples need to be carried out to analyze which technique presents superior results.

In a controlled study, Billici et al. (2018) evaluated the effectiveness of local anesthetic TPIs to the masticatory muscles for the treatment of TMD. The authors concluded that the study revealed significant decreases in pain scores; however, further studies are required.

In a controlled study, Ozkan et al. (2011) compared the effectiveness of combined treatment modalities using a stabilization splint and TPIs in the management of myofascial temporomandibular pain. The authors concluded that TPI therapy combined with splint therapy is effective in the management of myofascial temporomandibular pain. Further research, especially RCTs, is needed to ascertain the effectiveness over other treatment modalities.

In a double-blind, randomized, placebo-controlled study, Diracoglu et al. (2012) evaluated the safety and effectiveness of dry needling compared with sham dry needling in relieving myofascial pain of the temporomandibular muscles. Fifty-two individuals with established myofascial trigger points were randomly assigned into two groups. Dry needling was applied using acupuncture needles and sham dry needling was applied to the placebo group. Outcome measurements included pain pressure threshold measured with pressure algometry and VAS pain scores. Of the 52 individuals enrolled, 50 completed the study. Mean algometric values were statistically significantly higher in the dry needling group compared with the placebo group (P < 0.05). There was no statistically significant difference in VAS scores between the two groups. The authors concluded that dry needling was an effective treatment method to relieve pain in myofascial trigger points. The study is limited in its relatively small sample size and lack of mid-term or long-term follow-up. Additionally, the design of the study allowed for comparison between dry needling and sham placebo, with the result indicating that there was no difference in VAS pain scores.

In a retrospective study, Gonzalez-Perez et al. (2012) evaluated the safety and effectiveness of deep dry needling in the treatment of temporomandibular myofascial pain. Thirty-six individuals with myofascial pain were enrolled in the study. Outcome measurements included VAS pain scores and range of mandibular movements before and after intervention. A statistically significant difference between therapeutic intervention and improvement of pain and jaw movement was determined (P<0.01). Symptom improvement continued up to 6 months postintervention. The authors concluded that deep dry needling in trigger points may be effective in the treatment of temporomandibular myofascial pain. The study is limited in its relatively small sample size and lack of a comparative control group.

INTRA-ARTICULAR INJECTIONS FOR TMD
Intra-articular injections with local anesthetics or corticosteroids, although controversial, have been used for the treatment of inflammation within the TMJ capsule caused by an acute flair-up of degenerative joint disease or rheumatoid arthritis. The treatment should be used only for severe acute exacerbations or when conservative therapies have failed. Repeated corticosteroid injections are not recommended and should not be provided more than three times yearly with at least 3-month intervals between injections.

Peer-Reviewed Literature

Intra-articular injection using botulinum toxin, hyaluronic acid (HA), and ketamine injections have been used for the treatment of TMD. Currently, these injections are not US Food and Drug Administration (FDA)-approved for the treatment of TMD. The available published peer-reviewed literature indicates that the evidence is inconclusive regarding the effectiveness of these intra-articular injections for TMD.

OROFACIAL MYOFUNCTIONAL THERAPY (OMT)
Orofacial myofunctional therapy (OMT) involves the repatterning of the oral and facial muscles through proper tongue positioning and correct chewing and swallowing techniques. Head and neck posture patterns are also addressed. According to the Academy of Orofacial Myofunctional Therapy, treatment usually consists of a regular program of exercises over a 6- to 12-month period.

Peer-Reviewed Literature

In an RCT, de Felício et al. (2010) evaluated the effectiveness of OMT on TMDs. Thirty individuals with associated articular and muscular TMD were randomly divided into three groups. Ten were treated with OMT, 10 with an occlusal splint (OS), and 10 were untreated (control). An additional 10 individuals without TMD represented an asymptomatic group. All study participants had a clinical orofacial myofunctional evaluation (OME) pre- and postintervention. Individuals treated with OMT or OS had a statistically significant improvement, based on OME. Individuals treated with OMT also had an increased measure of mandibular range of motion, reduced frequency, and severity of symptoms. Although the results are promising, the study is limited in its heterogeneous comparative groups and small sample size. Long-term RCTs with appropriate comparative control groups and sufficient sample size are needed to establish the safety and effectiveness of OMT for the treatment of TMD.


LASER TREATMENT
Laser treatment, also known as photobiomodulation, has been used to treat the masseter and anterior temporalis muscles in individuals with TMD. Laser treatment refers to the use of red-beam or near-infrared lasers with a wavelength between 600 and 1000 nm and power from 5 to 500 MW. When applied to the skin, these lasers produce no sensation and do not burn the skin. Because of the low absorption by human skin, it is hypothesized that laser light can penetrate deeply into the tissues where it may have a photobiostimulative effect. The exact mechanism of its effect on tissue healing is currently unknown.

Peer-Reviewed Literature

In an RCT, Marini et al. (2010) evaluated the safety and effectiveness of super-pulsed low-level laser therapy (LLLT) compared with nonsteroidal anti-inflammatory drugs (NSAIDs) in the treatment of pain caused by TMD. Ninety-nine individuals with TMD secondary to disc displacement without reduction or osteoarthritis were randomly divided into three groups. Thirty-nine individuals received LLLT in 10 sessions over 2 weeks, 30 individuals received NSAIDs twice a day for 10 days, and 30 individuals received sham laser treatment as a placebo in 10 sessions over 2 weeks. Outcome measurements included VAS pain scores and mandibular range of motion. Mean VAS pain scores in the LLLT group were statistically significantly lower than in the NSAID or placebo group (P=0.0001) up to 1 month after treatment. The authors concluded that mandibular function improved with LLLT as demonstrated by improvements in symptoms related to TMD. The study is limited in its relatively small sample size, short-term follow-up period, and heterogeneous control groups.

In an RCT, da Silva et al. (2012) evaluated the safety and effectiveness of LLLT on individuals with intra-articular TMD. Forty-five individuals were divided into three groups of 15. Group one included individuals who received an energy dose of 15 J/cm2; group two included individuals who received an energy dose of 105 J/cm2; and group three consisted of individuals who received no energy dose (placebo). Two weekly sessions were held for 5 weeks, totaling 10 applications. Outcome measurements included mandibular range of movement and VAS pain scores. The authors found a statistically significant difference between groups 1 and 2. Based on these results, the authors concluded that the use of LLLT increased the mean mandibular range of motion and reduced pain in individuals with intra-articular TMD. The study is limited in its small sample size, lack of long-term follow-up, and heterogeneous comparative groups.

PROLOTHERAPY


Prolotherapy, also known as dextrose prolotherapy (DPT), is a regenerative injection technique used for osteoarthritis, chronic lower back pain, musculoskeletal pain, and joint pain. Prolotherapy is thought to work by injecting a small amount of irritant into painful joints, tendons, and ligaments, thereby promoting growth of normal cells and tissues. Dextrose is the most commonly used prolotherapy agent (Hauser et al., 2016).

 

Peer-Reviewed Literature

 

In an RCT, Zarate et al. (2020) reviewed whether dextrose and lidocaine intra-articular injections outperformed sterile water and lidocaine injections for pain, maximal jaw opening, and dysfunction associated with temporomandibular dysfunction. Twenty-nine participants in the blinded trial received intra-articular DPT versus intra-articular lidocaine at 0, 1, and 2 months. Participants were then unblinded and offered DPT by request for 9 additional months. The researchers found more DPT than lidocaine joints improved by 50% or more in both pain and dysfunction at 12 months. The study is limited by small participant size, lack of diversity, and need for long-term follow-up.


In a systematic review and meta-analysis of three RCTs, Nagori et al. (2018) assessed the efficacy of DPT in improving outcomes in TMJ hypermobility patients as compared with placebo. Frequency of subluxation/dislocation was reported by two trials that found no difference between dextrose and placebo. A statistically significant difference in reduction of maximal mouth opening (MMO) with the use of DPT was seen on pooling of data (random: MD = −3.32; 95% CI, −5.26 to −1.28; P=0.0008; I2=0%). A statistically significant difference in pain reduction was also seen with dextrose as compared with placebo (random: MD = −1; 95% CI, −1.58 to −0.42; P=0.0007; I2=0%). The researchers concluded that there is a need for more high-quality RCTs with larger sample size and homogenous prolotherapy protocol to draw stronger conclusions on the effect of DPT in patients with TMJ hypermobility.
 

In a randomized, double-blind, placebo-controlled clinical trial, Refai et al. (2011) studied 12 patients who were randomly assigned to two groups. The active group received four injections of dextrose solution for each TMJ, each 6 weeks apart; the placebo group received a placebo injection. They were assessed just before injection and 3 months after the last injection using a verbal scale regarding TMJ pain on palpation, MMO, clicking sound, and frequency of locking episodes per month. Both the active group and the placebo group showed significant improvement in TMJ pain on palpation and number of locking episodes and insignificant improvement in clicking sound. The active group showed a significant reduction in MMO at 12 weeks. The researchers concluded that prolotherapy appears promising; however, continued research with larger sample sizes and long-term follow up was needed. ​

SURGICAL TREATMENT OF TMD

Surgical treatment for TMD is controversial, often irreversible, and lacking in scientifically proven criteria. There exist meta-analyses of arthrocentesis, lavage, and arthroscopy for treating TMJ that cite equivocal findings. However, experts, professional organizations, and advocacy groups include surgery as one of the clinical approaches to treatment. Although many experts indicate that surgery should be considered when other treatments have failed, others suggest that nonresponse to conservative treatment does not automatically mean that surgery is necessary.

In literature reviews, absolute indications for surgery have been described as those in which surgical intervention has an undisputed role: tumors, growth anomalies, and ankylosis of the TMJ. Indications for TMJ surgery for internal derangement and osteoarthrosis include significant TMJ pain and dysfunction that are refractory to nonsurgical treatment, with radiologic evidence of disease. In surgical candidates, pain is localized to the TMJ, is moderate to severe, and becomes worse during jaw functions such as chewing or talking. Dysfunction may include painful clicking, crepitus, or locking of the TMJ. Limited mouth opening may be preceded by a period of painful clicking and intermittent locking.

The role of surgery for treatment of TMD has a long, controversial history. Procedures range from arthrocentesis to total joint replacement. There are no large RCTs trials determining the effectiveness of individual surgical procedures for any specific diagnosis or for the effectiveness of surgery versus other modalities. The only agreement among experts is that invasive treatments should be reserved for individuals with pain and dysfunction localized to the joint and refractory to nonsurgical therapies, and that the least invasive treatments should be provided first. Surgical treatment should be provided only after radiological confirmation of joint pathology and objective evidence of malfunction (e.g., insufficient interincisal mouth opening for routine dental care). According to the American Society of Temporomandibular Surgeons, the TMD conditions most likely to require surgery are internal derangement (disc displacement) and degenerative joint disease. Surgery has an undisputed role in treatment of other disorders such as neoplasia, ankylosis, and growth abnormalities. However, individuals who have pain and dysfunction arising from the masticatory muscles or other non-TMJ sources are not surgical candidates.

An array of surgical interventions, including arthrocentesis, arthroscopy, arthrotomy/arthroplasty, and TMJ replacement has been applied to the management of TMJ pathology. No surgical approach has been found to be specific for any diagnosis. Some studies cite no difference between arthroscopy, condylotomy, discectomy, and disc repositioning when provided to individuals with an internal derangement. Other studies indicate that both arthroscopic lysis and lavage and discectomy may be effective in reducing pain in individuals with chronic closed lock up to 10 years.

Although successful discectomy and insertion of an FDA-approved alloplastic partial prosthesis has been reported, discectomy with autogenous cartilage or dermal graft with or without disc replacement has also been advocated. Studies have found that when the disc is not replaced, new tissue forms between the condyle and fossa and acts as a pseudo disc, leading some to suggest that the need for disc replacement following discectomy for internal derangement is questionable. Additionally, in a retrospective study by De Leeuw et al. (1994), the authors demonstrated that in individuals with internal derangement and osteoarthritis who were treated nonsurgically, symptoms resolved and did not worsen after follow-up of up to 30 years.

When no other viable therapeutic alternatives are available, end-stage TMD may require reconstruction of the joint with a prosthetic device. For individuals who require total joint reconstruction, choices include autogenous or alloplastic reconstruction materials. The history of alloplastic surgical implants for treatment of TMD has been problematic. Prior to 1976, the FDA did not regulate medical devices. After that time, TMJ implants already on the market were allowed to continue as “grandfathered” devices without evidence of safety and effectiveness. This proved problematic for some individuals who received prostheses composed of Silastic and Teflon proplast that were used to replace discs and reconstruct the TMJ. These implants have since been removed from the market, but many individuals were left with multiply operated and degenerated joints. In 1993, the FDA began requiring manufacturers to submit the more rigorously reviewed Premarket Approval Application (PMA) for any implant on the market.

Alloplastic prostheses currently on the market include both total and partial devices. One type of total prosthesis is fitted to the patient using a model produced from a CT scan (Patient-Fitted Temporomandibular [TMJ] Reconstruction Prosthesis [TMJ Concepts, Ventura, CA]). Others are available for which the patient's tissues are adapted to fit the prosthesis (TMJ Fossa-Eminence/Condylar Prosthesis System,™ TMJ Medical, Golden, CO, and the Total Temporomandibular Joint Replacement System, Walter Lorenz Surgical Inc., Jacksonville, FL). A partial prosthesis (Fossa-Eminence Prosthesis,™ TMJ Medical, Golden, CO) is also available.

The problems with early prosthetic implants led to the use of autogenous grafts for tissue replacement or joint reconstruction. Temporalis flaps, auricular cartilage, and dermis grafts have been used mainly to replace failed implants, but there are drawbacks, including a second surgical site, prolonged surgical time, and a longer time to functionality. Although there have been failures, particularly in multiply operated individuals, autogenous reconstruction is still considered an option.

Peer-Reviewed Literature

In a retrospective study, Murakami et al. (2000) evaluated the long-term outcomes associated with arthroscopic surgery of the TMJ. A survey of 37 individuals who had been treated from 1986 to 1990 was undertaken. Thirty-three individuals responded, whose age at surgery ranged from 14 to 77 years. The mean follow-up period was 10 years and 2 months. Outcome measurements included VAS pain scores, jaw dysfunction, and activities of daily living (ADL) before and at the time of the survey. VAS pain scores had a statistically significant reduction from 5.15 to 0.34 (P<0.01). Dysfunction and ADL also had a statistically significant reduction (P<0.01). The authors concluded that the long-term treatment outcomes associated with arthroscopic surgery of the TMJ were considered to be acceptable and stable. The study is limited in its small sample size, retrospective study design, and potential bias associated with self-reported data.

In a retrospective study, Abd-Ul-Salam et al. (2002) evaluated the incidence of reoperation after TMJ arthroscopic surgery in 315 consecutive individuals. Study participants had a preoperative clinical and radiographic evaluation. Most had disc displacement without reduction. In the remaining individuals, intra-articular pathologic conditions ranged from disc displacement with reduction to degenerative joint disease. Outcome measurements included pain reduction, improvement in vertical dimension of mouth opening, and mandibular excursions. Prior to surgery, all participants received at least 3 to 6 months of nonsurgical therapy consisting of NSAIDs, splint therapy, ultrasound, or cold laser. Participants were followed for up to 5 years. Approximately 20% of the study participants who had TMJ arthroscopic surgery underwent additional TMJ procedures ranging from repeat arthroscopic surgery to open-joint arthrotomy. The authors concluded that for individuals with TMJ derangements, TMJ surgical arthroscopy was an appropriate therapeutic modality, with an acceptable reoperation rate. The study is limited in its retrospective study design and heterogeneous patient population.

In a comparative study, Wolford et al. (2003) evaluated the comparative outcomes of individuals treated with TMJ total joint prostheses using either the Christensen prosthesis (TMJ Medical, Golden, CO) or the TMJ Concepts prosthesis (TMJ Concepts Inc., Camarillo, CA). The Christensen prosthesis (CP) group consisted of 23 individuals and the TMJ Concepts prosthesis (TP) consisted of 22 individuals. The two groups had an average follow-up of 20.8 and 33.0 months, respectively. Outcome measurements included VAS pain scores, jaw function, and diet. The TP group had statistically significant improvements in all outcome measurements when compared with the CP group. The authors concluded that both groups showed good skeletal and occlusal stability, with better outcomes associated with TMJ improvement in the TP group. The study is limited in its lack of comparisons with nonsurgical controls.

In a prospective study, Wolford et al. (2003) evaluated the 5- to 8-year outcomes of 42 consecutive individuals who had TMJ reconstruction using the TMJ Concepts total joint prosthesis. Thirty-eight individuals were ultimately included in the study, with an average age of 36 years and average follow-up of 73.5 months. Outcome measurements included VAS pain scores, incisal opening, and jaw function. There were statistically significant improvements in incisal opening, jaw function, and pain level. Complications occurred in six individuals. The authors concluded that the TMJ Concepts total joint prosthesis was a viable technique for TMJ reconstruction in individuals with previous multiple TMJ procedures. The study is limited in its lack of a comparative control group.

In a systematic review, Vos et al. (2013) evaluated the safety and effectiveness of TMJ lavage when compared with nonsurgical treatment. Relevant outcome data included pain reduction as assessed by VAS pain score and MMO before and 6 months after treatment. Three RCTs representing 222 individuals were included for meta-analysis. There was a statistically significantly greater reduction in VAS pain scores after TMJ lavage when compared with nonsurgical treatment, although there was no statistically significant difference in MMO. The authors concluded that lavage of the TMJ may be slightly more effective than nonsurgical treatment for pain reduction; however, the difference is not likely to be clinically relevant.

VERTICAL DIMENSION 

In dentistry, vertical dimension of occlusion (VDO), sometimes called occlusal vertical dimension (OVD), indicates the superior-inferior relationship of the maxilla and the mandible when the teeth are situated in maximum intercuspation. Individuals who present with persistent pain or TMJ dysfunction may have teeth and supporting dental structures all within normal limits; however, if teeth have excessive wear, or if for some other reason there is loss of vertical dimension, correction to eliminate TMJ dysfunction may be required. Increasing vertical dimension is typically achieved by the application of dental crowns or bridgework, or if caused by malocclusion, orthodontia may be part of the treatment plan.​
SUMMARY

Because of the lack of understanding regarding the etiology of TMD, there are a variety of medical and surgical treatments available. Based on the available published peer-reviewed literature, clinical input, and guidelines from relevant medical societies, nonsurgical treatment should be considered first for all symptomatic individuals with TMD. Recommended treatment options include changes in diet, NSAIDs, physical therapy, maxillomandibular appliances (e.g., occlusal splints, bite plates), and intra-articular injections with local anesthetics or corticosteroids. In a select population, biofeedback or TPIs may be warranted.

The current scientific evidence is insufficient to permit conclusions regarding the safety and effectiveness of HA, botulinum, and ketamine injections for the treatment of TMD. The majority of the available literature is sparse and of low quality. Additionally, there is a paucity of evidence with respect to the treatment of TMD using electrical modalities including but not limited to transcutaneous and percutaneous electrical nerve stimulation, electrogalvanic stimulation, and iontophoresis percutaneous electrical nerve stimulation​. Although some evidence exists to support the use of orofacial myofunctional therapy for the treatment of TMD, the available literature remains of low quality (e.g., small sample size, short-term follow-up period, inadequate study design). There are few, if any, studies that support the safety and effectiveness of ultrasound treatment or orthognathic surgery for the treatment of TMD.

In a select population of individuals who are refractory to medical therapy, have clinically significant pain localized to the TMJ, and have evidence of mandibular malfunction, surgery may be indicated. Based on the available published peer-reviewed literature, clinical input, and guidelines from relevant medical societies, arthrocentesis, arthroscopy, and condylotomy may be considered medically appropriate for the treatment of TMD. In a select population, arthrotomy or arthroplasty may be indicated for individuals who are refractory to previous open surgery and have TMJ internal derangement and osteoarthrosis. Based on the available evidence, TMJ reconstruction may be indicated for adult individuals who have disarticulation due to trauma, joint degeneration, or destruction due to advanced degenerative joint disease, ankylosis, tumor, or complications of previously performed open surgery.​

References

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Company Benefit Contracts.

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Coding

CPT Procedure Code Number(s)
MEDICAL TREATMENT

PHYSICAL THERAPY
97024, 97110, 97112, 97124, 97140, 97530

THE FOLLOWING PROCEDURE CODE IS USED TO REPRESENT PROSTHETIC THERAPY
97799 

BIOFEEDBACK
90901

TRIGGER POINT THERAPY
20552, 20553

INTRA-ARTICULAR INJECTIONS
20605, 20606


SURGICAL TREATMENT

ARTHROCENTESIS
20605, 20606

ARTHROSCOPY
29804

ARTHROTOMY/ARTHROPLASTY
21010, 21240, 21242, 21243 

DISLOCATION OF JAW
21480, 21485, 21490

PROSTHESIS PREPARATION
21085, 21089, 21299

TEMPOROMANDIBULAR JOINT RECONSTRUCTION
20910, 21050, 21060, 21240, 21242, 21243, 21247 

THE FOLLOWING CODE IS USED TO REPRESENT CONDYLOTOMY:
20999​
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
M26.601 Right temporomandibular joint disorder, unspecified

M26.602 Left temporomandibular joint disorder, unspecified

M26.603 Bilateral temporomandibular joint disorder, unspecified

M26.609 Unspecified temporomandibular joint disorder, unspecified side

M26.611 Adhesions and ankylosis of right temporomandibular joint

M26.612 Adhesions and ankylosis of left temporomandibular joint

M26.613 Adhesions and ankylosis of bilateral temporomandibular joint

M26.619 Adhesions and ankylosis of temporomandibular joint, unspecified side

M26.621 Arthralgia of right temporomandibular joint

M26.622 Arthralgia of left temporomandibular joint

M26.623 Arthralgia of bilateral temporomandibular joint

M26.629 Arthralgia of temporomandibular joint, unspecified side

M26.631 Articular disc disorder of right temporomandibular joint

M26.632 Articular disc disorder of left temporomandibular joint

M26.633 Articular disc disorder of bilateral temporomandibular joint

M26.639 Articular disc disorder of temporomandibular joint, unspecified side

M26.641 Arthritis right temporomandibular joint

M26.642 Arthritis left temporomandibular joint

M26.643 Arthritis bilateral temporomandibular joint

M26.649 Arthritis unspecified temporomandibular joint

M26.69 Other specified disorders of temporomandibular joint
HCPCS Level II Code Number(s)
THE FOLLOWING CODE IS USED TO REPRESENT THE ALLOPLASTIC IMPLANT FOR TMJ RECONSTRUCTIVE SURGERY:
L8699 Prosthetic implant, not otherwise specified


PROCEDURES THAT ALTER VERTICAL DIMENSION
D7880 Occlusal orthotic device, by report; Presently includes splints provided for treatment of temporomandibular joint dysfunction.​

D7881 Occlusal orthotic device adjustment​

D9942 Repair and/or reline of occlusal guard

​ D9950 Occlusion analysis - mounted case; Includes, but is not limited to, facebow, interocclusal records tracings, and diagnostic wax-up; for diagnostic casts, see D0470.

D9951 Occlusal adjustment - limited; May also be known as equilibration; reshaping the occlusal surfaces of teeth to create harmonious contact relationships between the maxillary and mandibular teeth. Presently includes discing/odontoplasty/enamoplasty. Typically reported on a "per visit" basis. This should not be reported when the procedure only involves bite adjustment in the routine post-delivery care for a direct/indirect restoration or fixed/removable prosthodontics.

D9952 Occlusal adjustment - complete; Occlusal adjustment may require several appointments of varying length, and sedation may be necessary to attain adequate relaxation of the musculature. Study casts mounted on an articulating instrument may be utilized for analysis of occlusal disharmony. It is designed to achieve functional relationships and masticatory efficiency in conjunction with restorative treatment, orthodontics, orthognathic surgery, or jaw trauma when indicated. Occlusal adjustment enhances the healing potential of tissues affected by the lesions of occlusal trauma.
Revenue Code Number(s)
N/A


​

Coding and Billing Requirements

Policy History

Revisions From 07.08.03i:
02/26/2024

This policy will become effective 02/26/2024.


The following Medically Necessary surgical treatment has been added to the policy: ​Condylectomy.​


The Medically Necessary criteria for Temporomandibular Joint Disorder have been updated to include a heading for Procedures That Alter Vertical Dimension.
​

The following CPT codes have been added to this policy: 21050, 97799.


The following ICD-10 CM codes have been added to this policy:   

M26.609 Unspecified temporomandibular joint disorder, unspecified side
M26.619 Adhesions and ankylosis of temporomandibular joint, unspecified side
M26.629 Arthralgia of temporomandibular joint, unspecified side
M26.639 Articular disc disorder of temporomandibular joint, unspecified side
M26.649 Arthritis unspecified temporomandibular joint


The following HCPCS code has been removed from this policy: 


D9940 occlusal guard, by report; Removable dental appliances, which are designed to minimize the effects of bruxism (grinding) and other occlusal factors​​


Revisions From 07.08.03h:
10/10/2022

This policy will become effective 10/10/2022.


The following criteria have been added to this policy:


  • Prolotherapy is considered experimental/investigation for the treatment of temporomandibular joint dysfunction.​
​​The following ICD-10 CM codes have been removed from this policy: ​ 

M26.609 Unspecified temporomandibular joint disorder, unspecified side
M26.619 Adhesions and ankylosis of temporomandibular joint, unspecified side
M26.629 Arthralgia of temporomandibular joint, unspecified side
M26.639 Articular disc disorder of temporomandibular joint, unspecified side
M26.649 Arthritis unspecified temporomandibular joint​​​

Revisions From 07.08.03g:
06/16/2021

The policy has been reviewed and reissued to communicate the Company's continuing position on Medical and Surgical Treatment of Temporomandibular Joint Disorder​.​

​11/30/2020
​The version of this policy will become effective 11/30/2020.

The following CPT codes have been removed from the policy: 20560, 20561​, and 97010.

Revisions From 07.08.03f:
10/01/2020

This policy has been identified for the ICD-10 CM code update effective 10/01/2020.


The following ICD-10 CM codes have been added as eligible to be reported for Medical and Surgical Treatment of Temporomandibular Joint Disorder:

M26.641: Arthritis right temporomandibular joint

M26.642: Arthritis left temporomandibular joint

M26.643: Arthritis bilateral temporomandibular joint

M26.649: Arthritis unspecified temporomandibular joint​


Revisions From 07.08.03e:
01/01/2020 This policy has been identified for the CPT code update, effective 01/01/2020.

The following CPT codes have been added to the policy:

20560; 20561 (Medically Necessary)

Revisions From 07.08.03d:
04/24/2019This policy has been reissued in accordance with the Company's annual review process.
06/25/2018The policy has undergone a routine review, and the code narratives has been revised for the following codes D9940, D9950, D9951, D9952.

Effective 10/05/2017 this policy has been updated to the new policy template format.
2/26/2024
2/26/2024
07.08.03
Medical Policy Bulletin
Commercial
No
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.