Temporomandibular Joint Dysfunction

Background: The dysfunction of the temporomandibular joint (TMJ) becomes a significant and serious problem for modern society. TMJ disorder is the pathology of the stomatognathic system that is encountered more and more often every year, because the etiology is different and the pathogenesis is not well investigated. This disease is the result of the action of many factors that are constantly related to each other and over time can intensify and aggravate each other. A large number of studies have been done, articles and scientific papers have been published on the subject to establish the degree of prevalence and severity of this disease. Every year there are more and more patients with this pathology, which would mean that an effective solution in solving this problem has not yet been found and the topic remains relevant to this day. Insufficient knowledge of the mechanisms of this disease is one of the main reasons for the ineffectiveness of the treatment methods used. The objective of the work was to identify the clinical relevance of temporomandibular joint diseases. Conclusions: TMJ dysfunction is a topic that does not lose its relevance, because it is still a problem to identify the causes of pathologies of the TMJ and their treatment. TMJ pathology can be caused by various factors, the identification of this problem should be approached with all seriousness, taking into account all diagnostic methods and a high-quality anamnesis taken from the patient.

• Magnetic resonance imaging (MRI) of the temporomandibular joint (TMJ) for evaluation of internal derangement or disc displacement when BOTH of the following requirements are met: o Mechanical symptoms (such as locking, popping, or clicking) which have not improved after at least 3 months of conservative management, including nonsteroidal anti-inflammatory drugs or acetaminophen, a short-term trial of soft diet and proper chewing techniques, and an oral appliance (such as a bite block); AND o Surgical intervention is being considered; OR • Cephalograms (x-rays of jaws and skull); OR • Pantograms (x-rays of maxilla and mandible).

When Services Are Considered Investigational
Coverage is not available for investigational medical treatments or procedures, drugs, devices or biological products.
Based on review of available data, the Company considers diagnostic procedures in the diagnosis of temporomandibular joint dysfunction (TMJD), including but not limited to the following procedures, to be investigational*: • Electromyography (EMG), including surface electromyography (EMG); • Kinesiography; • Thermography; • Neuromuscular junction testing; • Somatosensory testing; • Transcranial or lateral skull x-rays; intraoral tracing or gnathic arch tracing (intended to demonstrate deviations in the positioning of the jaw that are associated with temporomandibular joint dysfunction [TMJD]); • Muscle testing; • Standard dental radiographic procedures; • Range-of-motion measurements; • Computerized mandibular scan (measures and records muscle activity related to movement and positioning of the mandible and is intended to detect deviations in occlusion and muscle spasms related to temporomandibular joint dysfunction [TMJD]); • Ultrasound imaging/sonogram; • Arthroscopy of the temporomandibular joint (TMJ) for purely diagnostic purposes; • Joint vibration analysis.

Nonsurgical Treatments When Services Are Eligible for Coverage
Coverage for eligible medical treatments or procedures, drugs, devices or biological products may be provided only if: • Benefits are available in the member's contract/certificate, and • Medical necessity criteria and guidelines are met.
Based on review of available data, the Company may consider ANY of the following nonsurgical treatments in the treatment of temporomandibular joint dysfunction (TMJD) to be eligible for coverage**: • Intraoral removable prosthetic devices/appliances (encompassing fabrication, insertion, adjustment); OR • Pharmacologic treatment (e.g., anti-inflammatory, muscle relaxing, analgesic medications).

When Services Are Considered Investigational
Coverage is not available for investigational medical treatments or procedures, drugs, devices or biological products.
Based on review of available data, the Company considers nonsurgical treatments in the treatment of temporomandibular joint dysfunction (TMJD), including but not limited to the following treatments, to be investigational*: •

When Services Are Eligible for Coverage
Coverage for eligible medical treatments or procedures, drugs, devices or biological products may be provided only if: • Benefits are available in the member's contract/certificate, and • Medical necessity criteria and guidelines are met.
Based on review of available data, the Company may consider ANY of the following surgical treatments in the treatment of temporomandibular joint dysfunction (TMJD) to be eligible for coverage**: • Arthrocentesis; OR • Manipulation for reduction of fracture or dislocation of the temporomandibular joint (TMJ); OR • Arthroscopic surgery in patients with objectively demonstrated (by MRI or CT imaging) internal derangements (displaced discs) or degenerative joint disease (DJD) who have failed conservative treatment, e.g., the individual tried and failed non-surgical therapies for at least 3 months with documented compliance. Therapies should include behavioral changes, pharmacological therapy, and/or reversible intraoral appliances; OR • Open surgical procedures (when temporomandibular joint dysfunction [TMJD] is the result of congenital anomalies, trauma, or disease) including, but not limited to, arthroplasties; condylectomies; meniscus or disc plication, and disc removal in patients who have objectively documented abnormalities and who have failed conservative treatment, e.g., the individual tried and failed non-surgical therapies for at least 3 months with documented compliance. Therapies should include behavioral changes, pharmacological therapy, and/or reversible intraoral appliances.

When Services Are Considered Investigational
Coverage is not available for investigational medical treatments or procedures, drugs, devices or biological products.
Based on review of available data, the Company considers all other surgical treatments in the treatment of temporomandibular joint dysfunction (TMJD) to be investigational.*

Diagnosis of Temporomandibular Joint Disorder
In the clinical setting, temporomandibular joint disorder (TMJD) is often a diagnosis of exclusion and involves physical examination, patient interview, and a review of dental records. Diagnostic testing and radiologic imaging are generally only recommended for patients with severe and chronic symptoms. Diagnostic criteria for TMJD have been developed and validated for use in both clinical and research settings.
Symptoms attributed to TMJD vary and include, but are not limited to, clicking sounds in the jaw; headaches; closing or locking of the jaw due to muscle spasms (trismus) or displaced disc; pain in the ears, neck, arms, and spine; tinnitus; and bruxism (clenching or grinding of the teeth).

Treatment
For many patients, symptoms of TMJD are short-term and self-limiting. Conservative treatments (eg, eating soft foods, rest, heat, ice, avoiding extreme jaw movements) and anti-inflammatory medication are recommended before considering more invasive and/or permanent therapies (eg, surgery).
Note that low-level laser therapy for TMJD is addressed in medical policy 00194, and botulinum toxin for TMJD is addressed in medical policy 00012.

Rationale/Source
This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. Food and Drug Administration approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

Description
Temporomandibular joint disorder (TMJD) refers to a group of disorders characterized by pain in the temporomandibular joint and surrounding tissues. Initial conservative therapy is generally recommended; there are also a variety of nonsurgical and surgical treatment possibilities for patients whose symptoms persist.

Summary of Evidence
For individuals with suspected TMJD who receive ultrasound, surface electromyography, or joint vibration analysis, the evidence includes systematic reviews of diagnostic test studies. Relevant outcomes are test validity and other performance measures. None of the systematic reviews found that these diagnostic techniques accurately identified patients with TMJD, and many of the studies had methodologic limitations. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.
For individuals with a confirmed diagnosis of TMJD who receive intraoral devices or appliances or pharmacologic treatment, the evidence includes randomized controlled trials (RCTs) and systematic reviews of RCTs. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. A systematic review of intraoral appliances (44 studies) and metaanalyses of subsets of these studies found a significant benefit of intraoral appliances compared with control interventions. Several studies, meta-analyses, and systematic reviews exploring the effectiveness of stabilization splints on TMJD pain revealed conflicting results. Overall, the evidence shows that stabilizing splints may improve pain and positively impact depressive and anxiety symptoms. The evidence related to pharmacologic treatment varies because studies, systematic reviews, and meta-analyses lack consistency in evaluating specific agents. Some systematic reviews have found a significant benefit of several pharmacologic treatments (eg, analgesics, muscle relaxants, and anti-inflammatory medications [ No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from Blue Cross and Blue Shield of Louisiana.

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benefit with agents such as methylprednisolone and botulinum toxin type A. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.
For individuals with a confirmed diagnosis of TMJD who receive acupuncture, biofeedback, transcutaneous electrical nerve stimulation, orthodontic services, hyaluronic acid, platelet concentrates, or dextrose prolotherapy, the evidence includes RCTs, systematic reviews of these RCTs, and observational studies. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The systematic reviews did not find that these technologies reduced pain or improved functional outcomes significantly more than control treatments. Moreover, many individual studies were small and/or had methodologic limitations. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.
For individuals with a confirmed diagnosis of TMJD who receive arthrocentesis or arthroscopy, the evidence includes RCTs, systematic reviews of RCTs, and observational studies. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. One review, which included 3 RCTs, compared arthrocentesis or arthroscopy with nonsurgical interventions for TMJD. Pooled analyses of the RCTs found that arthrocentesis and arthroscopy resulted in superior pain reduction compared with control interventions. A network meta-analysis, which included 36 RCTs, revealed that arthroscopy and arthrocentesis improve pain control and maximum mouth opening. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

Supplemental Information Practice Guidelines and Position Statements
Guidelines or position statements will be considered for inclusion in 'Supplemental Information if they were issued by, or jointly by, a US professional society, an international society with US representation, or National Institute for Health and Care Excellence (NICE). Priority will be given to guidelines that are informed by a systematic review, include strength of evidence ratings, and include a description of management of conflict of interest.

American Association for Dental, Oral, and Craniofacial Research
In 2010 (reaffirmed in 2015), the American Association for Dental Research (now the American Association for Dental, Oral, and Craniofacial Research) policy statement recommended the following for the diagnosis and treatment of temporomandibular joint disorders (TMJDs): "It is recommended that the differential diagnosis of TMDs [temporomandibular disorders] or related orofacial pain conditions should be based primarily on information obtained from the patient's history, clinical examination, and when indicated, TMJ [temporomandibular joint] 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…." "It is strongly recommended that, unless there are specific and justifiable indications to the contrary, treatment of TMD patients initially should be based on the use of conservative, reversible and evidence-based therapeutic modalities. Studies of the natural history of many TMDs suggest that they tend to improve or resolve over time. While no specific therapies have been proven to be uniformly effective, many of the conservative modalities have proven to be at least as effective in providing symptomatic relief as most forms of invasive treatment…."

American Society of Temporomandibular Joint Surgeons
In 2001, the American Society of Temporomandibular Joint Surgeons issued consensus clinical guidelines focused on TMJDs associated with internal derangement and osteoarthritis. For diagnosis of this type of TMJD, a detailed history and, when indicated, a general physical examination was recommended. Imaging of the temporomandibular and associated structures was also recommended. Options for basic radiography to provide information on temporal bone and condylar morphology included the use of plain films, panoramic films, and tomograms. Also recommended was imaging of the disc and associated soft tissue with magnetic resonance imaging or arthrography. Other diagnostic procedures indicated included computed tomography, magnetic resonance imaging (MRI), arthrography (for selected cases) and isotope bone scans.
Nonsurgical treatment was recommended as first-line therapy for all symptomatic patients with this condition. Recommended treatment options included a change in diet, nonsteroidal antiinflammatory drugs, maxillomandibular appliances, physical therapy, injections of corticosteroids or botulinum toxin, and behavior modification. If adequate symptom relief did not occur within 2 to 3 weeks, surgical consultation was advised. The guideline stated the following surgical procedures were considered accepted and effective for patients with TMJDs associated with internal derangement or osteoarthritis: • Arthrocentesis • Arthroscopy • Condylotomy • Arthrotomy (prosthetic joint replacement may be indicated in selected patients who have severe joint degeneration, destruction, or ankylosis) • Coronoidotomy/coronoidectomy • Styloidectomy

U.S. Preventive Services Task Force Recommendations
Not applicable.

Medicare National Coverage
There is no national coverage determination. In the absence of a national coverage determination, coverage decisions are left to the discretion of local Medicare carriers.

Ongoing and Unpublished Clinical Trials
Some currently ongoing and unpublished trials that might influence this review are listed in Table  2. *Investigational -A medical treatment, procedure, drug, device, or biological product is Investigational if the effectiveness has not been clearly tested and it has not been incorporated into standard medical practice. Any determination we make that a medical treatment, procedure, drug, device, or biological product is Investigational will be based on a consideration of the following: A. Whether the medical treatment, procedure, drug, device, or biological product can be lawfully marketed without approval of the U.S. Food and Drug Administration (FDA) and whether such approval has been granted at the time the medical treatment, procedure, drug, device, or biological product is sought to be furnished; or B. Whether the medical treatment, procedure, drug, device, or biological product requires further studies or clinical trials to determine its maximum tolerated dose, toxicity, safety,