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Horizon BCBSNJ
Uniform Medical Policy ManualSection:Medicine
Policy Number:079
Effective Date: 02/15/2016
Original Policy Date:05/27/2014
Last Review Date:04/09/2019
Date Published to Web: 11/12/2015
Subject:
Temporomandibular Joint Disorder

Description:
_______________________________________________________________________________________

IMPORTANT NOTE:

The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.

Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.

__________________________________________________________________________________________________________________________

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.

PopulationsInterventionsComparatorsOutcomes
Individuals with:
 Suspected temporomandibular joint disorder
Interventions of interest are:
 Ultrasound
 Surface electromyography
 Joint vibration analysis
Comparators of interest are:
 Comprehensive history and physical exam
 Alternative diagnostic test
Relevant outcomes include:
 Test validity
 Other test performance measures
Individuals with:
 Confirmed diagnosis of temporomandibular joint disorder
Interventions of interest are:
 Intraoral devices or appliances
 Pharmacologic treatment
Comparators of interest are:
 Alternative nonsurgical intervention
Relevant outcomes include:
 Symptoms
 Functional outcomes
 Quality of life
 Treatment-related morbidity
Individuals with:
 Confirmed diagnosis of temporomandibular joint disorder
Interventions of interest are:
 Acupuncture
 Biofeedback
 Transcutaneous electrical nerve stimulation
 Orthodontic services
 Hyaluronic acid
Comparators of interest are:
 Alternative nonsurgical intervention
Relevant outcomes include:
 Symptoms
 Functional outcomes
 Quality of life
 Treatment-related morbidity
Individuals with:
 Confirmed diagnosis of temporomandibular joint disorder
Interventions of interest are:
 Arthrocentesis
 Arthroscopy
Comparators of interest are:
 Nonsurgical intervention
Relevant outcomes include:
 Symptoms
 Functional outcomes
 Quality of life
 Treatment-related morbidity

Background

Temporomandibular Joint Disorder

TMJD (also known as temporomandibular joint syndrome) refers to a cluster of problems associated with the temporomandibular joint and musculoskeletal structures. The etiology of TMJD remains unclear and is believed to be multifactorial. TMJD is often divided into two main categories: articular disorders (eg, ankylosis, congenital or developmental disorders, disc derangement disorders, fractures, inflammatory disorders, osteoarthritis, joint dislocation) and masticatory muscle disorders (eg, myofascial pain, myofibrotic contracture, myospasm, neoplasia).

Diagnosis

In the clinical setting, TMJD is often a diagnosis of exclusion and involves physical examination, patient interview, and a review of dental records. Diagnostic testing and radiologic imaging aregenerally 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.1,2,3,

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 evidence review 2.01.56, and botulinum toxin for TMJD is addressed in evidence review 5.01.05.

Regulatory Status

Since 1981, several muscle-monitoring devices have been cleared for marketing by the U.S. Food and Drug Administration 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 TMJD. Food and Drug Administration product code: KZM.

Table 1. Muscle-Monitoring Devices Cleared by the U.S. Food and Drug Administration
Devices
Manufacturer
Date Cleared
510(k) No.
Indication
K6-I Diagnostic SystemMyotronics, IncJun 1994K922456Electromyography
BioEMG IIITMBio-Research Associates, IncFeb 2009K082927Electromyography, Joint Vibration Recording
M-ScanTMBio-Research AssociatesJul 2013K130158Electromyography
GrindCare MeasureMedotech A/SApr 2012K113677Electromyography, Nocturnal Bruxism


Related Policies:

  • Electrotherapies in Pain Management (Policy #025 in the Treatment Section)
  • Biofeedback (Policy #060 in the Treatment Section)
  • Sodium Hyaluronate Injections (Policy #015 in the Treatment Section)
  • Low-Level Laser Therapy (Policy #074 in the Treatment Section)
  • Botulinum Toxin (Policy #059 in the Treatment Section)

Policy:
(NOTE: For Medicare Advantage, please refer to the Medicare Coverage Section below for coverage guidance.)

1. The following diagnostic procedures are considered medically necessary in the diagnosis of temporomandibular joint disorder (TMJD):
    • Diagnostic x-ray, tomograms, and arthrograms;
    • Computed tomography (CT) scan or magnetic resonance imaging (MRI) (in general, CT scans and MRIs are reserved for pre-surgical evaluations);
    • Cephalograms (x-rays of jaws and skull);
    • Pantograms (x-rays of maxilla and mandible).

    (NOTE: Cephalograms and pantograms should be reviewed on an individual basis.)

2. The following diagnostic procedures are considered investigational in the diagnosis of TMJD:
    • Electromyography (EMG), including surface EMG;
    • Kinesiography;
    • Thermography;
    • Neuromuscular junction testing;
    • Somatosensory testing;
    • Transcranial or lateral skull x-rays; Intra-oral tracing or gothic arch tracing (intended to demonstrate deviations in the positioning of the jaws that are associated with 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 TMJD);
    • Ultrasound imaging/sonogram;
    • Arthroscopy of the temporomandibular joint (TMJ) for purely diagnostic purposes;
    • Joint vibration analysis.
3. The following nonsurgical treatments are considered medically necessary in the treatment of TMJD:
    • Intra-oral removable prosthetic devices or appliances (encompassing fabrication, insertion, and adjustment);
    • Pharmacologic treatment (eg, anti-inflammatory, muscle relaxing, and analgesic medications).
4. The following nonsurgical treatments are considered investigational in the treatment of TMJD:
    • Electrogalvanic stimulation;
    • Iontophoresis;
    • Biofeedback;
    • Ultrasound;
    • Devices promoted to maintain joint range of motion and to develop muscles involved in jaw function;
    • Orthodontic services;
    • Dental restorations/prostheses;
    • Transcutaneous electrical nerve stimulation;
    • Percutaneous electrical nerve stimulation;
    • Acupuncture;
    • Hyaluronic acid.
5. The following surgical treatments are considered medically necessary in the treatment of TMJD:
    • Arthrocentesis;
    • Manipulation for reduction of fracture or dislocation of the TMJ;
    • Arthroscopic surgery in members with objectively demonstrated (by physical examination or imaging) internal derangements (displaced discs) or degenerative joint disease who have failed conservative treatment;
    • Open surgical procedures (when TMJD results from congenital anomalies, trauma, or disease in members who have failed conservative treatment) including, but not limited to, arthroplasties; condylectomies; meniscus or disc plication and disc removal.


Medicare Coverage:
There is no National Coverage Determination (NCD) or Local Coverage Determination (LCD) specific to Temporomandibular Joint Dysfunction. There are multiple NCDs and LCDs on the proposed treatments for TMJ in the Horizon BCBSNJ Medical Policy. For further information, please refer to the following:

National Coverage Determination (NCD) for Acupuncture 30.3. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=11&ncdver=1&bc=AAAAgAAAAAAA&.

National Coverage Determination (NCD) for Thermography 220.11. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=164&ncdver=1&bc=AAAAgAAAAAAA&.

National Coverage Determination (NCD) for Biofeedback Therapy 30.1. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=41&ncdver=1&bc=AAAAgAAAAAAA&.
National Coverage Determination (NCD) for Transcutaneous Electrical Nerve Stimulators (TENS) (280.13). Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=273&ncdver=2&bc=AAAAgAAAAAAA&.

Local Coverage Determination (LCD) L33802 Transcutaneous Electrical Nerve Stimulators (TENS). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33802&ContrId=389&ver=18&ContrVer=1&CntrctrSelected=389*1&Cntrctr=389&s=38&DocType=All&bc=AggAAAQAAAAA&.


[RATIONALE: This policy was created in April 2014 and has been updated regularly with searches of the MEDLINE database. The most recent literature update was performed through December 6, 2018.

Evidence reviews assess the clinical evidence to determine whether the use of technology improves the net health outcome. Broadly defined, health outcomes are the length of life, quality of life (QOL), and ability to function¾including benefits and harms. Every clinical condition has specific outcomes that are important to patients and managing the course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is a balance of benefits and harms.

To assess whether the evidence is sufficient to draw conclusions about the net health outcome of technology, two domains are examined: the relevance, and quality and credibility. To be relevant, studies must represent one or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. For some conditions, the alternative will be supportive care or surveillance. The quality and credibility of the evidence depend on study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial (RCT) is preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate. RCTs are rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice.

For treatment of temporomandibular joint disorders (TMJD), literature searches have focused on studies comparing novel treatments with conservative interventions and/or placebo controls (rather than no-treatment control groups) and reporting pain reduction and/or functional outcome improvements (eg, jaw movement).

Diagnosis of TMJD

Clinical Context and Test Purpose

The purpose of specific diagnostic tests in patients with suspected TMJD is to provide a treatment option that is an alternative to or an improvement on existing diagnostic approaches, such as a comprehensive history and physical exam and alternative diagnostic tests.

The question addressed in this policy is: do specific diagnostic tests improve the net health outcome for individuals with suspected TMJD?

The following PICOTS were used to select literature to inform this review.

Patients

The relevant population of interest are individuals with suspected TMJD.

Interventions

The diagnostic tests being considered are ultrasound, surface electromyography, and joint vibration analysis.

Comparators

Comparators of interest include a comprehensive history and physical exam and alternative diagnostic tests. Alternative diagnostic tests can include routine dental x-rays, panoramic radiographs, computed tomography, magnetic resonance imaging, and scintigraphy.

Outcomes

The general outcomes of interest are test validity, and other test performance measures.

Timing

The existing literature evaluating ultrasound, surface electromyography, and joint vibration analysis as diagnostic tests for suspected TMJD has varying lengths of follow-up. While studies described below all reported at least one outcome of interest, longer follow-up was necessary to fully observe outcomes. Therefore, at least one year of follow-up is considered necessary to demonstrate efficacy.

Setting

Patients with suspected TMJD are managed by primary care providers, dentists, and otolaryngologists in an outpatient clinical setting.

Study Selection Criteria

Below are selection criteria for studies to assess whether a test is clinically valid.

a. The study population represents the population of interest. Eligibility and selection are described.

b. The test is compared with a credible reference standard.

c. If the test is intended to replace or be an adjunct to an existing test; it should also be compared with that test.

d. Studies should report sensitivity, specificity, and predictive values. Studies that completely report true- and false-positive results are ideal. Studies reporting other measures (eg, Receiver Operating Characteristic, Area Under the Receiver Operating Curve, c-statistic, likelihood ratios) may be included but are less informative.

e. Studies should also report reclassification of diagnostic or risk category.

Several systematic reviews of the literature on specific techniques for diagnosing TMJD were identified and are described next.

Ultrasound

A 2009 literature review identified 20 studies evaluating ultrasound for diagnosing TMJDs; all studies evaluated disc displacement and several also considered osteoarthrosis and/or joint effusion.4, The reported sensitivity of ultrasound to detect disc displacement, compared with the reference standard (magnetic resonance imaging in most studies), ranged from 31% to 100%, and the specificity ranged from 30% to 100%. Reviewers stated that even when changes in ultrasound technology over time were taken into account, study findings were contradictory. They noted unexplained differences between studies conducted by the same group of researchers. Reviewers concluded that additional advances are needed to standardize the ultrasound assessment of TMJD before it can be considered an accurate diagnostic tool.

Surface Electromyography

A 2006 systematic review of surface electromyography found a lack of literature on the accuracy of this method of diagnosis, compared with a criterion standard (ie, comprehensive clinical examination and history-taking).5 Reviewers concluded there was insufficient evidence that electromyography can accurately identify people with facial pain from those without pain, but that the technique may be useful in a research setting.

Joint Vibration Analysis

Sharma et al (2013) published a systematic review on joint vibration analysis for diagnosis of TMJDs.6, Reviewers identified 15 studies that evaluated the reliability and/or diagnostic accuracy of joint vibration analysis compared with a reference standard. Methodologic limitations were identified in all studies and included the absence of well-defined diagnostic criteria, use of a nonvalidated system for classifying disease progression, variability within studies in the reference standard used, and lack of blinding. In the 14 studies reporting on diagnostic accuracy, there was a wide range of reported values, with sensitivity ranging from 50% to 100% and specificity ranging from 59% to 100%.

Section Summary: Diagnosis of TMJD

Current evidence is insufficient or imprecise to support the use of ultrasound, surface electromyography or joint vibration analysis to diagnose TMJD.

Treatment of TMJD

Clinical Context and Therapy Purpose

The purpose of orthotics and pharmacologic treatment in patients with a confirmed diagnosis of TMJD is to provide a treatment option that is an alternative to or an improvement on existing therapies, such as alternative nonsurgical intervention.

The question addressed in this policy is: do orthotics and pharmacologic treatment improve the net health outcome for individuals with a confirmed diagnosis of TMJD?

The following PICOTS were used to select literature to inform this review.

Patients

The relevant population of interest are individuals with confirmed TMJD.

Interventions

The therapies being considered are intraoral devices or appliances and pharmacological treatment. Intraoral devices and appliances are described in the Regulatory Status section above and can include stabilization splints. Pharmacological treatment can include nonsteroidal anti-inflammatory drugs, opioids, corticosteroids, muscle relaxants, antidepressants, anticonvulsants, and benzodiazepines.

Comparators

The main comparators of interest are alternative nonsurgical intervention, such as medications, physical therapy, and injections. Alternative medicine techniques can also be used, such as acupuncture, relation techniques, TENS, and biofeedback.

Outcomes

The general outcomes of interest are symptoms, functional outcomes, QOL, and treatment-related morbidity. Symptoms of TMJD may include, pain, tenderness, or aching in the jaw or one or both of the temporomandibular joints, difficulty or pain while chewing, and locking of the temporomandibular joint.

Timing

The existing literature evaluating intraoral devices or appliances and pharmacologic treatment as a treatment for confirmed TMJD has varying lengths of follow-up, ranging from six weeks to one year of follow-up. While the systematic reviews described below all reported at least one outcome of interest, longer follow-up was necessary to fully observe outcomes. Therefore, at least one year of follow-up is considered necessary to demonstrate efficacy.

Setting

Patients with confirmed TMJD are actively managed by primary care providers, dentists, and otolaryngologists in an outpatient clinical setting.

Study Selection Criteria

Methodologically credible studies were selected using the following principles:

a. To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;

b. In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.

c. To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.

d. Studies with duplicative or overlapping populations were excluded.

Systematic Reviews

List and Axelsson (2010) published a review of systematic reviews on treatments for TMJD published through August 2009.7, They identified 30 reviews; there were 23 qualitative systematic reviews and 7 meta-analyses. Eighteen of the systematic reviews included only RCTs, three only included case-control studies, and nine included a mix of RCTs and case series. TMJDs were defined inconsistently in the primary studies and systematic reviews, and several reviews addressed the related diagnoses of bruxism, disc replacements, and myofascial pain. Twenty-nine of the systematic reviews had pain intensity or pain reduction as the primary outcome measure, and 25 reported clinical outcome measures such as jaw movement or jaw tenderness on palpation. Reviewers divided the treatments into five categories (some studies were included in >1 category). These categories and the main findings are listed in Table 2.

Table 2. Categories of Treatment
CategoriesNo. of ArticlesFindings
Occlusal appliances, occlusal adjustment, and orthodontic treatment10Six systematic reviews did not find significant benefit vs other treatments, 4 found no benefit vs a placebo device, and 3 found occlusal therapy was better than no treatment.
Physical treatments including acupuncture, TENS, exercise, and mobilization8Four reviews found no significant benefit of acupuncture over other treatments, 1 found no difference between acupuncture and placebo treatment, and 3 found acupuncture was better than no treatment. One review found active exercise and postural training were effective for treating TMJD-related pain.
Pharmacologic treatment7Treatments found to be superior to placebo were analgesics (2 reviews), clonazepam or diazepam (3 reviews), antidepressants (4 reviews), and hyaluronate (1 review). One review found effects of hyaluronate and corticosteroids to be similar.
Maxillofacial surgery4Three reviews evaluated surgery for patients with disc displacements and 1 addressed orthognathic surgery in patients with TMJD. Reviews of surgical treatments generally included lower level evidence (eg, case series), and did not always compare surgery with a control condition. One review of patients with disc displacements with reduction reported similar treatment effects for arthrocentesis, arthroscopy, and discectomy, and another review in patients in disc displacement without reduction found similar effects of arthrocentesis, arthroscopy, and physical therapy (used as a control intervention). Due to the lack of high-quality controlled studies, conclusions could not be drawn about intervention equivalence.
Behavioral therapy and multimodal treatments6Two reviews found biofeedback to be better than active control or no treatment, 1 review found a combination of biofeedback and CBT to be better than no treatment, and 2 found a combination of biofeedback and relaxation to be better than no treatment. One review found the effects of biofeedback and relaxation to be similar.
Adapted from List and Axelsson (2010).7,
CBT: cognitive-behavioral therapy; TENS: transcutaneous electrical nerve stimulation; TMJD: temporomandibular joint disorders.

Overall, reviewers concluded there was insufficient evidence that electrophysical modalities and surgery would be effective for treating TMJD. They found some evidence that occlusal appliances, acupuncture, behavioral therapy, jaw exercises, postural training, and some medications could be effective at reducing pain for patients with TMJDs. However, reviewers noted that most of the systematic reviews examined included primary studies with considerable variation in methodologic quality and, thus, it was not possible to draw definitive conclusions about the effectiveness of any of the treatments.

Randhawa et al (2016) published a systematic review of noninvasive interventions for TMJDs, which included RCTs with at least 30 individuals per treatment arm, cohort studies with at least 100 patients per exposed group, and case-control interventions.8, Reviewers identified 31 studies for appraisal, of which 7 RCTs described in 8 publications had a low-risk of bias and were assessed further. Most RCTs evaluated interventions outside the scope of our review, including cognitive-behavioral therapy and self-care management. Three RCTs evaluated occlusal devices for TMJDs of variable duration and generally reported no significant improvements with occlusal devices regarding pain, mouth opening, or other outcomes.

ORTHOTICS

Intraoral Devices or Appliances

Fricton et al (2010) reported on a systematic review of RCTs on the intraoral treatment of TMJDs and identified 47 publications on 44 trials.9, Intraoral appliances included soft and hard stabilization appliances, anterior positioning appliances, anterior bite appliances, and soft resilient appliances. Studies compared two types of devices or compared one device with different treatment (eg, acupuncture or biofeedback). None of the studies evaluated the use of onedevice during the day and a different device during the night. The primary outcome of the meta-analysis was pain reduction. The pain was measured differently in the studies, and reviewers defined a successful outcome as at least a 50% reduction in pain on a self-report scale or at least an “improved” status when the pain was measured by the subjective report of status. Ten RCTs were included in two meta-analyses; the others were excluded because they did not measure pain, there were not at least two studies using similar devices or control groups, or data were not usable for pooled analysis. A pooled analysis of 7 RCTs (n=385 patients) that evaluated hard stabilization appliances and use of palatal nonoccluding appliances as a control found a significantly greater reduction in pain with hard appliances (odds ratio, 2.45; 95% confidence interval [CI], 1.56 to 3.86; p<0.001). A pooled analysis of 3 studies (n=216 patients) did not find a statistically significant effect of hard appliances compared with a no-treatment control group (odds ratio, 2.14; 95% CI, 0.80 to 5.75; p=0.12).

Ivorra-Carbonell et al (2016) reported on a systematic review of functional advancement devices for TMJD, which included systematic reviews, meta-analyses, RCTs, case-control studies, and cohort studies, assessed using PRISMA methodology.10, Reviewers included 21 articles evaluating some advancement device, considered of medium- or high-quality by CONSORT criteria. Results were summarized descriptively; reviewers concluded that, after treatment with mandibular advancement, the condyle was in “more advanced position.”

Stabilization Splints

Ebrahim et al (2012) identified 11 RCTs comparing splint therapy for TMJDs with minimal or no therapy.11, Nine of the 11 studies used stabilization splints, 1 used soft splints, and 1 used an anterior repositioning appliance. Reviewers used the GRADE system to rate study quality. Nine studies did not report whether allocation was concealed, and six studies did not report masking outcome assessors. Length of follow-up in the studies ranged from 6 to 52 weeks. A pooled analysis of study findings found that splint therapy was significantly associated with a reduction in reported pain compared with minimal or no intervention (standardized mean difference, -0.93; 95% CI, -1.33 to -0.53). Using a 100-millimeter visual analog scale (VAS) to measure pain, splint therapy was associated with an 11.5 mm lower mean VAS score (95% CI, -16.5 to -6.6 mm). There were no statistically significant differences between groups in QOL or depression scores.

Zhang et al (2016) identified 13 publications from 11 studies (n=538 patients) evaluating splint therapy for TMJDs.12, Risk of bias was high for two or more domains for all studies. Splint therapy group patients had greater improvements in pain control than control patients (mean difference, 2.02; 95% CI, 1.55 to 2.49; I2=0.558).

An earlier Cochrane review by Al-Ani et al (2004) identified 12 RCTs that compared stabilization splint therapy for TMJD with a control intervention.13, (The control group was not limited to minimal or no intervention as in the Ebrahim review.) There was wide variability in the comparison interventions and no standardization of outcomes; thus, study results could not be pooled. This Cochrane review was withdrawn in 2016 for being out of date and not meeting current Cochrane methodologic standards.14,

Pharmacologic Treatment

Häggman-Henrikson et al (2017) published a systematic review that included 41 RCTs assessing various pharmacologic regimens for pain from TMJDs or burning mouth syndrome; of these, 13 were selected for a network meta-analysis.15, Nine studies evaluated temporomandibular muscular pain, which appeared to decrease more with cyclobenzaprine than with placebo, although no specific statistics were reported. Pain reduction was also favorable for botulinum toxin and Ping-On ointment in the meta-analysis; other descriptive analyses showed a reduction of pain with nonsteroidal anti-inflammatory drugs and melatonin tablets when compared with placebo.

Section Summary: Orthotics and Pharmacologic Treatment

Evidence evaluating the use of orthotics in the treatment of TMJD, while sometimes conflicting and inconclusive, suggests that use of orthotics reduces TMJD pain. A systematic review found that different pharmacologic agents reduced pain in patients with TMJD. A systematic review of intraoral appliances (44 studies) and meta-analyses of subsets of these studies found a significant benefit of intraoral appliances compared with control interventions. Other systematic reviews have found a significant benefit of several pharmacologic treatments (eg, analgesics, muscle relaxants, and anti-inflammatory medications [vs placebo]). The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Other Nonsurgical Therapies

Clinical Context and Therapy Purpose

The purpose of nonsurgical therapies in patients with a confirmed diagnosis of TMJD is to provide a treatment option that is an alternative to or an improvement on existing therapies, such as alternative nonsurgical intervention.

The question addressed in this policy is: do nonsurgical therapies improve the net health outcome for individuals with a confirmed diagnosis of TMJD?

The following PICOTS were used to select literature to inform this review.

Patients

The relevant population of interest are individuals with confirmed TMJD.

Interventions

The nonsurgical therapies being considered are acupuncture, biofeedback, TENS, orthodontic services, and hyaluronic acid.

Comparators

The main comparator of interest is alternative nonsurgical intervention, such as medications.

Outcomes

The general outcomes of interest are symptoms, functional outcomes, QOL, and treatment-related morbidity. Symptoms of TMJD are described in the second PICOTS above.

Timing

The existing literature evaluating nonsurgical therapies as a treatment for confirmed TMJD has varying lengths of follow-up, ranging from one week to six months of follow-up. While the systematic reviews and RCTs described below all reported at least one outcome of interest, longer follow-up was necessary to fully observe outcomes. Therefore, at least one year of follow-up is considered necessary to demonstrate efficacy.

Setting

Patients with confirmed TMJD are actively managed by primary care providers, dentists, and otolaryngologists in an outpatient clinical setting.

Study Selection Criteria

Methodologically credible studies were selected using the following principles:

a. To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;

b. In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.

c. To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.

d. Studies with duplicative or overlapping populations were excluded.

Acupuncture

A 2011 systematic review and meta-analysis identified 7 sham-controlled randomized trials evaluating acupuncture for treating TMJD.16, The studies included a total of 141 patients. Sample sizes of individual studies ranged from 7 to 28 patients. Four studies used a single acupuncture session, and the other 3 used 6 to 12 sessions. All seven studies reported a change in pain intensity as assessed by VAS. In 6 of the studies, pain intensity was measured immediately after treatment; the seventh measured pain after 16 weeks. A pooled analysis of findings from 5 studies (n=107 patients) found a statistically significant reduction in pain intensity, as measured by VAS. The pooled weighted mean difference (WMD) in pain intensity was -13.63 (95% CI, -21.16 to -6.10; p<0.001). A pooled subgroup analysis of 4 studies (n=89 patients) found acupuncture to be superior to a nonpenetrating sham acupuncture (WMD = -13.73; 95% CI, -21.78 to -5.67; p<0.001). A pooled analysis of 2 studies (n=18 patients) did not find a significant difference in efficacy between acupuncture and a penetrating sham acupuncture (WMD = -12.95; 95% CI, -34.05 to 8.15; p=0.23). The latter analysis might have been underpowered. Reviewers noted that previous studies had found that a 24.2-mm change in pain assessed by a 100-mm VAS represents a clinically significant difference and that only 2 of the selected studies had a change of 24.2 mm or more.

Orthodontic Services

A Cochrane review by Luther et al (2010) did not identify any RCTs evaluating orthodontic treatment for TMJDs and thus concluded there was insufficient evidence on the efficacy of orthodontics.17, Reviewers defined orthodontic treatment as appliances that would induce stable tooth movement for a sufficient period to bring about permanent change in tooth position. The 2010 Cochrane review was withdrawn in 2016 for being out of date and not meeting current Cochrane methodologic standards18,; a new Cochrane review on occlusal interventions for managing TMJDs is planned.

Hyaluronic Acid Injection

Systematic Reviews

Several systematic reviews of studies have assessed the use of hyaluronic acid for treating TMJDs.19,20,21,22, Only one systematic review limited its inclusion criteria to RCTs and pooled study findings¾the Cochrane review by Shi et al (2013).21, The Shi et al (2013) review included RCTs comparing the effect of at least 1 hyaluronic acid injection alone or in combination with other active treatments to placebo or glucocorticoid injections alone or in combination with the same active treatment group. Seven studies met inclusion criteria: three studies compared hyaluronic acid with placebo, three studies compared hyaluronic acid with glucocorticoids, and two studies compared hyaluronic acid plus arthroscopy or arthrocentesis with arthroscopy or arthrocentesis alone. (One study included three arms and was included in the first two comparisons.) Five of the 7 studies included fewer than 50 participants.

Outcomes were categorized as symptoms, which reflected the subjective feeling and the judgment of the patients, and clinical signs, which reflected the objective judgment of the observer. A meta-analysis of 2 trials did not find a statistically significant difference between hyaluronic acid and placebo for short-term (<3 months) improvement in symptoms (relative risk [RR], 1.24; 95% CI, 0.72 to 2.14). Similarly, a pooled analysis of 3 trials did not find a significant difference between hyaluronic acid and placebo for short-term improvement of clinical signs (RR=1.69; 95% CI, 0.80 to 3.57). However, a pooled analysis of 2 studies found a statistically significant between-group difference in long-term effect (≥3 months) on clinical signs (RR=1.71; 95% CI, 1.05 to 2.77). For the comparison between hyaluronic acid and glucocorticoids, only short-term data were available for pooling. There were no significant differences between groups for short-term improvement in symptoms (2 studies; RR=0.99; 95% CI, 0.84 to 1.17) or short-term improvement in clinical signs (3 studies; RR=0.91; 95% CI, 0.66 to 1.25). Data were not pooled for studies of combination treatments (hyaluronic acid plus arthroscopy or arthrocentesis). Reviewers found there was insufficient, consistent evidence to draw conclusions on the use of hyaluronate for treating patients with TMJDs. This Cochrane review was withdrawn in 2013 for being out of date and not meeting contemporary Cochrane methodologic standards.23,

Liu et al (2017) conducted a systematic review and meta-analysis of RCTs or cohort studies that compared temporomandibular osteoarthritis outcomes in patients treated with intra-articular corticosteroid, hyaluronate, or placebo injection.24, All eight selected studies were RCTs; of these, three contained data on hyaluronate injection. Compared with placebo, corticosteroid injections prompted a significant decrease in long-term (ie, ≥6 months postprocedure) pain (3 studies; mean difference, -0.74; 95% CI, -1.34 to -0.13; p=0.02; I2=0%). However, in a pooled analysis of 2 studies (both of which included pretreatment arthrocentesis), long-term maximal mouth opening was increased for placebo more than for corticosteroid injection (mean difference, -2.06; 95% CI, -2.76 to -1.36; p<0.001; I2=28%). Only two studies were available for comparing corticosteroid with hyaluronate injections, which precluded strong analysis. Short-term pain and mouth opening measures did not significantly differ between any of the injection groups, nor did the incidence of adverse events. The meta-analysis was limited by the small sample sizes of included trials, as well as by the variety of corticosteroid types used. Reviewers concluded that corticosteroid injection following arthrocentesis may be effective for relief of long-term joint pain but may be less effective for improving mouth opening.

Randomized Controlled Trials

Most published RCTs evaluating hyaluronic acid for treating TMJDs have had small sample sizes, short follow-up times, and/or lacked blinding. Representative RCTs with larger sample sizes and stronger methodology are described next.

Gorrela et al (2017) reported on the efficacy of injecting sodium hyaluronate in patients with TMJDs.25, The trial comprised 62 individuals with the disorder; some members (n=31) of the trial were treated with arthrocentesis, and some members (n=31) were treated by a combination of arthrocentesis and an injection of sodium hyaluronate. Follow-up was observed at one week, two weeks, one month, three months, and at six months. Using a VAS, patients were asked to measure pain from one to ten. Pain decreased significantly for patients in both treatment groups (p<0.001) at the one week and the six-month follow-up; however, patients who were injected with sodium hyaluronate reported a significantly stronger decrease in pain at the six-month follow-up (p<0.001). Preoperative mean VAS pain scores for patients who received injection started at 6.0; by the 6-month follow-up, the mean VAS pain score was 0.23. Preoperative mean pain scores for patients who received arthrocentesis alone started at 6.77; by the 6-month follow-up, the mean pain score was 1.71. While not an overwhelmingly significant difference, the trialists concluded that adding an injection of sodium hyaluronate to arthrocentesis treatment can significantly decrease the pain felt by patients who suffer from TMJD.

A study by Manfredini et al (2012) in Italy randomized 72 patients with TMJD to 1 of 6 treatment groups: (1) single-session arthrocentesis alone; (2) single-session arthrocentesis plus corticosteroid; (3) single-session arthrocentesis plus low-molecular-weight hyaluronic acid; (4) single-session arthrocentesis plus high-molecular-weight hyaluronic acid; (5) 5 weekly arthrocenteses plus low-molecular-weight hyaluronic acid; or (6) 5 weekly single-needle arthrocenteses plus low-molecular-weight hyaluronic acid.26 Sixty (83%) of 72 participants completed the study, with between 9 and 12 patients per treatment group. In a per-protocol analysis, there were no significant differences among groups on any of the outcome variables at the three-month follow-up. For example, the percentage change in pain at rest ranged from -29.1% in the group receiving 5 weekly single-needle arthrocentesis plus low-molecular-weight hyaluronic acid injections to, -38.4% in the group receiving a single-session of arthrocentesis alone. Trial limitations included the small number of patients in each treatment group and the substantial number of dropouts in the absence of an intention-to-treat analysis.

A study by Bjornland et al (2007) in Norway evaluated 40 patients with osteoarthritis of the TMJD in a double-blind RCT.27, Patients received 2 injections, 14 days apart, of sodium hyaluronate or corticosteroids. The pain was assessed using a VAS ranging from 0 to 100. Patients were followed for 6 months (assessed at 14 days, 1 month, and 6 months). There was a statistically significant reduction in pain within each group at all follow-up points. At the 6-month follow-up, pain intensity (mean VAS score) was 14 in the hyaluronic acid group and 31 in the corticosteroid group; the between-group difference was statistically significant (p<0.001). The number of patients who were pain-free at 6 months was 7 (35%) of 20 in the hyaluronic acid group and 6 (30%) of 20 in the corticosteroid group (p-value not reported).

Bertolami et al (1993) published a double-blind placebo-controlled trial that evaluating 121 patients with TMJD.28, Patients had to have a confirmed diagnosis of degenerative joint disease, reducing displaced disc or nonreducing displaced disc (DDN), failure of other nonsurgical treatments, and severe dysfunction. Patients received a single injection of sodium hyaluronate or saline and were followed for six months. Eighty patients were randomized to the hyaluronate group and 41 to the placebo group. This included 57 patients in the degenerative joint disease group, 50 patients in the reducing displaced disc group, and 14 patients in the DDN group. Fourteen (12%) of 121 patients were excluded from the analysis because they did not meet eligibility criteria. Seven outcomes were assessed, including three measures of dysfunction, two measures of patient perception of improvement, and two measures of change in noise. No significant differences in outcomes were seen for the degenerative joint disease group. In the DDN group, there were significant between-group differences through one month, favoring the hyaluronic acid group. The number of patients in the DDN group who completed follow-up after one month was insufficient to draw meaningful conclusions about efficacy. The most consistent between-group differences in the reducing displaced disc group were for the two measures of patient perception of improvement and one of the noise variables. There were fewer between-group differencesin dysfunction measures.

Section Summary: Nonsurgical Therapies

A systematic review evaluating the use of orthodontic services to treat TMJD did not find sufficient literature to draw conclusions about efficacy. The evidence on acupuncture is limited by the small number of studies, small sample sizes, and in most studies, efficacy assessment only immediately posttreatment. The evidence on the use of hyaluronic acid to treat TMJD is inconclusive, given the methodologic issues with the systematic review and RCTs conducted (eg, small sample sizes) and better surgical options. Overall, the evidence is insufficient to determine that the technologies result in a meaningful improvement in the net health outcome.

Surgical Techniques

Clinical Context and Therapy Purpose

The purpose of surgical techniques in patients with a confirmed diagnosis of TMJD is to provide a treatment option that is an alternative to or an improvement on existing therapies, such as nonsurgical intervention.

The question addressed in this policy is: do surgical therapies improve the net health outcome for individuals with a confirmed diagnosis of TMJD?

The following PICOTS were used to select literature to inform this review.

Patients

The relevant population of interest are individuals with confirmed TMJD.

Interventions

The surgical therapies being considered are arthrocentesis and arthroscopy.

Comparators

The main comparators of interest are alternative nonsurgical intervention, such as intraoral devices and appliances, pharmacologic treatment, acupuncture, biofeedback, TENS, orthodontic services, and hyaluronic acid.

Outcomes

The general outcomes of interest are symptoms, functional outcomes, QOL, and treatment-related morbidity. Symptoms of TMJD are described in the second PICOTS above.

Timing

The existing literature evaluating surgical techniques as a treatment for confirmed TMJD has varying lengths of follow-up up to six months. While the systematic reviews described below all reported at least one outcome of interest, longer follow-up was necessary to fully observe outcomes. Therefore, at least six months of follow-up is considered necessary to demonstrate efficacy.

Setting

Patients with confirmed TMJD are actively managed by primary care providers, dentists, and otolaryngologists in an outpatient clinical setting.

Study Selection Criteria

Methodologically credible studies were selected using the following principles:

a. To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;

b. In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.

c. To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.

d. Studies with duplicative or overlapping populations were excluded.

A Cochrane review by Guo et al (2009) identified 2 RCTs (total n=81 patients) that compared the effectiveness of arthrocentesis plus lavage with arthroscopy for the treatment of TMJD.29,Data were pooled only for the outcome of maximum incisal opening. A meta-analysis of the 2 trials found a statistically significant difference between the interventions for this outcome, with a WMD of -5.28 (95% CI, -7.10 to -3.46), favoring arthroscopy. The Cochrane review was withdrawn in 2015 for being out of date and not meeting current Cochrane methodologic standards.30, Another Cochrane review (2015) reporting on arthroscopy for TMJD was also withdrawn from Cochrane from 2015 for being out of date and not meeting current Cochrane methodologic standards.31,

In a systematic review, Vos et al (2013) identified 3 RCTs (total n=222 patients) that compared the efficacy of lavage of the temporomandibular joint (ie, arthrocentesis or arthroscopy) with nonsurgical temporomandibular joint treatment.32, Although reviewers assessed the quality of the studies to be adequate, only one stated that allocation to treatment group was concealed; two did not explicitly state use of an intention-to-treat analysis. The two primary outcomes considered were change in pain and maximal mouth opening at six months compared with baseline. The pain was measured by VAS. Pooled analysis of data from the 3 trials found a statistically significant reduction in pain at 6 months with surgery plus lavage vs nonsurgical therapy (standardized mean difference = -1.07; 95% CI, -1.38 to -0.76). There was no statistically significant difference in the efficacy between the 2 treatments for the other outcome variable, maximal mouth opening (standardized mean difference=0.05; 95% CI, -0.33 to 0.23).

In a retrospective cohort study, Hossameldin and McCain (2018) assessed the efficacy of an office-based TMJ arthroscopic technique. The researchers assessed the following outcomes of the procedure: improvement in painless range-of-motion in the mandible, reduced pain on loading, and improvement in functional jaw pain. The cohort included an initial 363 patients, excluded 41, and an analysis was performed on the joints of the remaining 322 that were compromised. Within the 322 patients, 452 joints were operated on with a 66.6% (n=301 joints) success rate (p=.001). It is stated within the outcome variable section that the primary outcome variable of success or failure was determined by the reduction of joint pain postoperatively. This could be subjective. When the operation failed (n=151 joints, 33.3%), 141 joints were involved in a subsequent procedure that ranged from more advanced arthroscopy to a total joint replacement.36

Section Summary: Surgical Techniques

Systematic reviews of the literature, which includes RCTs, have shown that the use of arthrocentesis and arthroscopy reduces pain levels in patients with TMJD.

Summary of Evidence

For individuals who have suspected TMJD who receive ultrasound, surface electromyography, or joint vibration analysis, the evidence includes systematic reviews of diagnostic test studies. The 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 the effects of the technology on health outcomes.

For individuals who have a confirmed diagnosis of TMJD who receive intraoral devices or appliances or pharmacologic treatment, the evidence includes RCTs and systematic reviews of the RCTs. The relevant outcomes are symptoms, functional outcomes, QOL, and treatment-related morbidity. A systematic review of intraoral appliances (44 studies) and meta-analyses of subsets of these studies found a significant benefit of intraoral appliances compared with control interventions. Other systematic reviews have found a significant benefit of several pharmacologic treatments (eg, analgesics, muscle relaxants, and anti-inflammatory medications [vs placebo]). The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have a confirmed diagnosis of TMJD who receive acupuncture, biofeedback, transcutaneous electrical nerve stimulation, orthodontic services, or hyaluronic acid, the evidence includes RCTs, systematic reviews of these RCTs, and observational studies. The relevant outcomes are symptoms, functional outcomes, QOL, 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 the effects of the technology on health outcomes.

For individuals who have a confirmed diagnosis of TMJD, who receive arthrocentesis or arthroscopy, the evidence includes RCTs and systematic reviews of the RCTs. The relevant outcomes are symptoms, functional outcomes, QOL, and treatment-related morbidity. Only one review, which included three 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. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

SUPPLEMENTAL INFORMATION

Practice Guidelines and Position Statements

American Association for Dental Research

A 2010 policy statement, reaffirmed in 2015, by the American Association for Dental Research recommended the following for the diagnosis and treatment of temporomandibular joint disorders (TMJDs)33,:

“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

Consensus clinical guidelines by the American Society of Temporomandibular Joint Surgeons (2001) focused on TMJDs associated with internal derangement and osteoarthritis.34, 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 is 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, 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 include a change in diet, nonsteroidal anti-inflammatory drugs, maxillomandibular appliances, physical therapy, injections of corticosteroids or botulinum toxin, and behavior modification. If adequate symptom relief did not occur within two to three 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.

American Dental Association

Selected statements from the American Dental Association’s practice parameters for TMJDs, last revised in 1997, included35,:

· “Initially the dentist should select the least invasive and most reversible therapy that may ameliorate the patient’s pain and/or functional impairment.”

· “The dentist should evaluate the effectiveness of initial therapy prior to considering more invasive and/or irreversible therapy.”

· “When articular derangement and/or condylar dislocation has been determined to be the etiology of the patient’s pain and/or functional impairment, manual manipulation of the mandible may be performed by the dentist.

· “Oral orthotics (guards/splints) may be used by the dentist to enhance diagnosis, facilitate treatment or reduce symptoms.

· “Before restorative and/or occlusal therapy is performed, the dentist should attempt to reduce, through the use of reversible modalities, the neuromuscular, myofascial and temporomandibular joint symptoms.

· “The dentist may replace teeth, alter tooth morphology and/or position by modifying occluding, articulating, adjacent or approximating surfaces, and by placing or replacing restorations (prostheses) to facilitate treatment.

· “Transitional or provisional restorations (prostheses) may be utilized by the dentist to facilitate treatment.

· “Intracapsular and/or intramuscular injection, and/or arthrocentesis may be performed for diagnostic and/or therapeutic purposes.

· “Orthodontic therapy may be utilized to facilitate treatment.

· “Orthognathic surgery may be performed to facilitate treatment.

· “When internal derangement or pathosis has been determined to be the cause of the patient’s pain and/or functional impairment, arthroscopic or open resective or reconstructive surgical procedures may be performed by the dentist.”

U.S. Preventive Services Task Force Recommendations

Not applicable.

Ongoing and Unpublished Clinical Trials

Some currently unpublished trials that might influence this review are listed in Table 3.

Table 3. Summary of Key Trials
NCT No.Trial NamePlanned EnrollmentCompletion Date
Ongoing
NCT02839967Influence of Intraoral Phototherapy on Pain, Joint Mobility, Functionality and Quality of Life in Individuals With Temporomandibular Joint Dysfunction
30
Jan 2018
NCT02437383Effect of COMT (Catecholamine-O-methyltransferase) Genetic Polymorphisms on Response to Propranolol Therapy in Temporomandibular Disorder
200
Apr 2018
NCT03180671The Effectiveness of Anterior Deprogrammers as a Tool for Reducing Pain and Masticatory Muscles
80
May 2019
NCT03029494The Role of Oxidative Stress and Opio[r]phin in Temporomandibular Disorders
80
Sep 2019
Unpublished
NCT02397070Effectiveness of a Jaw Exercise Program in Temporomandibular Disorder Patients
30
Jul 2015

(unknown)

NCT02637544Treatment Efficacy of Acupuncture in Non-Chronified Pain Patients with TMDs
40
Aug 2016
NCT02880774Influence of Manual Therapy in Temporomandibular Joint on the Mandibular Movement: Clinical Trial, Randomized, Placebo-controlled and Blind
24
Aug 2016
NCT02822469Thermograph Evaluation of Masticatory Muscles Pre and Post Indirect Physiotherapeutic Treatment in TMD Subjects: A Randomized, Placebo-controlled Study
32
Dec 2016
NCT02602483aRandomized, Double Blind, Placebo Controlled Exploratory Study To Assess the Efficacy and Safety of a Triple Combination of Ibuprofen+Mg+Ascorbic Acid for Acute Pain Treatment in Temporomandibular Joint Disorder (TMJD) Patients
96
Dec 2016 (completed)
NCT02908568Effect of Stimulation of the Proprioceptive Trigeminocardiac Reflex through Medical Device for the Pain of Patients with Temporomandibular Disorders
36
Aug 2017
NCT: national clinical trial.

a Denotes industry-sponsored or cosponsored trial.]

________________________________________________________________________________________

Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

___________________________________________________________________________________________________________________________

Index:
Temporomandibular Joint Disorder
Temporomandibular Joint Dysfunction
Acupuncture, TMJ Dysfunction
Arthrocentesis, TMJ Dysfunction
Arthroscopy, TMJ Dysfunction
Biofeedback, TMJ Dysfunction
Cephalograms, TMJ Dysfunction
Electromyography (EMG), TMJ Dysfunction
EMG (Electromyography), TMJ Dysfunction
Gothic Arch Tracing, TMJ Dysfunction
Intra-Oral Tracing, TMJ Dysfunction
Iontophoresis, TMJ Dysfunction
Kinesiography, TMJ Dysfunction
Medical Treatment, TMJ Dysfunction
Neuromuscular Junction Testing, TMJ Dysfunction
Pantograms, TMJ Dysfunction
PENS (Percutaneous Electrical Nerve Stimulation)
Physical Therapy, TMJ Dysfunction
Sonograms, TMJ Dysfunction
Temporomandibular Joint (TMJ) Dysfunction/Syndrome
TENS (Transcutaneous Electrical Nerve Stimulation), TMJ Dysfunction
TMJ (Temporomandibular Joint) Dysfunction/Syndrome

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34. American Society of Temporomandibular Joint Surgeons. Guidelines for diagnosis and management of disorders involving the temporomandibular joint and related musculoskeletal structures. 2001; http://astmjs.org/final%20guidelines-04-27-2005.pdf. Accessed January 26, 2018.

35. American Dental Association. Temporomandibular (Craniomandibular) Disorders. 1997; http://www.ada.org/1958.aspx. Accessed January 26, 2018.

36. Hossameldin RH, McCain JP. Outcomes of office-based temporomandibular joint arthroscopy: a 5-year retrospective study. Int J Oral Maxillofac Surg. Jan 2018;47(1):90-97.


Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*

    20605
    20606
    21010
    21116
    21050
    21060
    21073
    21240
    21242
    21243
    29800
    29804
    64553
    64555
    64561
    64568
    64569
    64570
    64575
    64580
    64581
    64585
    64590
    64595
    70328
    70330
    70332
    70336
    70350
    70355
    70486
    70487
    70488
    76100
    76101
    76102
    76999
    90875
    90876
    90901
    95867
    95868
    95927
    95937
    95999
    96000
    96001
    96002
    96003
    96004
HCPCS
    A4595
    E0720
    E0730
    E1700
    E1701
    E1702
    J7321
    J7323
    J7324
    J7325
    J7326
    J7327
    J7328
    S3900

* CPT only copyright 2019 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.

The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy

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