CAM 20121

Temporomandibular Joint Dysfunction

Category:Medicine   Last Reviewed:August 2019
Department(s):Medical Affairs   Next Review:August 2020
Original Date:July 2010    

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.

For individuals who have suspected TMJD who receive ultrasound, surface electromyography, or joint vibration analysis, the evidence includes systematic reviews of diagnostic test studies. Relevant outcomes are test accuracy, 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 randomized controlled trials (RCTs) and systematic reviews of the RCTs. Relevant outcomes are symptoms, functional outcomes, quality of life, 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 (e.g., 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. 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 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. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Only 1 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. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Background 
TEMPOROMANDIBULAR JOINT DISORDER
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 2 main categories: articular disorders (e.g., ankylosis, congenital or developmental disorders, disc derangement disorders, fractures, inflammatory disorders, osteoarthritis, joint dislocation) and masticatory muscle disorders (e.g., 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 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.1-3 

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 (e.g., eating soft foods, rest, heat, ice, avoiding extreme jaw movements) and anti-inflammatory medication are recommended before considering more invasive and/or permanent therapies (e.g., surgery).

Note that low-level laser therapy for TMJD is addressed in evidence review 20156, and botulinum toxin for TMJD is addressed in evidence review 50105.

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 System

Myotronics, Inc

Jun 1994

K922456

Electromyography

BioEMG IIITM

Bio-Research Associates, Inc

Feb 2009

K082927

Electromyography, Joint Vibration Recording

M-ScanTM

Bio-Research Associates

Jul 2013

K130158

Electromyography

GrindCare Measure

Medotech A/S

Apr 2012

K113677

Electromyography, Nocturnal Bruxism

KZM

Related Policies
10109 Transcutaneous Electrical Nerve Stimulation
20130 Biofeedback for Chronic Pain
20131 Intra-Articular Hyaluronan Injections for Osteoarthritis
20156 Low-Level Laser Therapy
50105 Botulinum Toxin
70129 Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy

Policy 
DIAGNOSTIC PROCEDURES
The following diagnostic procedures may be 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 presurgical evaluations);
  • Cephalograms (x-rays of jaws and skull);
  • Pantograms (x-rays of maxilla and mandible).

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

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; intraoral tracing or gnathic arch tracing (intended to demonstrate deviations in the positioning of the jaw 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.

NONSURGICAL TREATMENTS
The following nonsurgical treatments may be considered MEDICALLY NECESSARY in the treatment of TMJD:

  • Intraoral removable prosthetic devices or appliances (encompassing fabrication, insertion, adjustment);
  • Pharmacologic treatment (e.g., anti-inflammatory, muscle relaxing, analgesic medications).

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. 

SURGICAL TREATMENTS
The following surgical treatments may be considered MEDICALLY NECESSARY in the treatment of TMJD:

  • Arthrocentesis;
  • Manipulation for reduction of fracture or dislocation of the TMJ;
  • Arthroscopic surgery in patients 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 patients who have failed conservative treatment) including, but not limited to, arthroplasties; condylectomies; meniscus or disc plication, and disc removal. 

Benefit Application
BLUECARD/NATIONAL ACCOUNT  ISSUES
Plans may want to review their contract language on the diagnosis and treatment of temporomandibular joint disorder (TMJD) to ensure that the language is consistent with the Plan’s medical policy on TMJD. Some contracts may exclude coverage for TMJD.

Dental contracts frequently exclude the diagnosis and treatment of TMJD. Services excluded may include, but are not limited to, orthodontics, equilibration of the teeth, dental radiographs, and dental prosthesis, whether performed by a dentist or a physician. Other Plans may limit TMJD diagnosis and treatment only to the dental portion of the contract. 

Denial of the investigational procedure is applicable for contracts or certificates of coverage that maintain an exclusion for investigational services.

Claims may be received for psychiatric or psychological visits in relation TMJD, because this condition may be psychosomatic in origin, resulting from tension or stress. Bruxism is a common symptom of tension, which may lead to symptoms suggestive of TMJD.

Plans should determine whether contract limitations for physical therapy are applicable to temporomandibular joint treatment.

Prognathism (protruding jaw), micrognathism (small lower jaw), or apertognathism (open bite) may be associated with TMJD in some people. Plans should review contracts to ensure coverage or exclusion of coverage, as well as medical vs dental coverage in individual cases.

Claims may be received for the treatment of TMJD with, but not limited to, the following diagnoses and symptoms:

  • Cranial-cervical syndrome
  • Myofascial pain/dysfunction syndrome
  • Asymmetrical motor neuropathy
  • Cervicalgia
  • Localized myospasm
  • Cephalgia
  • Musculoskeletal dysfunction
  • Neural entrapment
  • Myalgia/myositis. 

Rationale 
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 function---including 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 uses 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 evidence review 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. 

  1. The study population represents the population of interest. Eligibility and selection are described. 
  2. The test is compared with a credible reference standard.
  3. If the test is intended to replace or be an adjunct to an existing test; it should also be compared with that test.
  4. 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.
  5. 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 evidence review 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:  

  1. To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;
  2. In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
  3. To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.
  4. 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 

Categories

No. of Articles

Findings

Occlusal appliances, occlusal adjustment, and orthodontic treatment

10

Six 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 mobilization

8

Four 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 treatment

7

Treatments 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 surgery

4

Three 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 treatments

6

Two 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 one device 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 evidence review 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:  

  1. To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;
  2. In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
  3. To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.
  4. 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.19-22 Only one systematic review limited its inclusion criteria to RCTs and pooled study findings---the 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 differences in 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 evidence review 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:  

  1. To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;
  2. In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
  3. To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.
  4. 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.

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."
  • "ntracapsular 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 Name

Planned Enrollment

Completion Date

Ongoing 

NCT02839967

Influence of Intraoral Phototherapy on Pain, Joint Mobility, Functionality and Quality of Life in Individuals With Temporomandibular Joint Dysfunction

30

Jan 2018

NCT02437383

Effect of COMT (Catecholamine-O-methyltransferase) Genetic Polymorphisms on Response to Propranolol Therapy in Temporomandibular Disorder

200

Apr 2018

NCT03180671

The Effectiveness of Anterior Deprogrammers as a Tool for Reducing Pain and Masticatory Muscles

80

May 2019

NCT03029494

The Role of Oxidative Stress and Opio[r]phin in Temporomandibular Disorders

80

Sep 2019

Unpublished 

NCT02397070

Effectiveness of a Jaw Exercise Program in Temporomandibular Disorder Patients

30

Jul 2015  (unknown)

NCT02637544

Treatment Efficacy of Acupuncture in Non-Chronified Pain Patients with TMDs

40

Aug 2016

NCT02880774

Influence of Manual Therapy in Temporomandibular Joint on the Mandibular Movement: Clinical Trial, Randomized, Placebo-controlled and Blind

24

Aug 2016

NCT02822469

Thermograph Evaluation of Masticatory Muscles Pre and Post Indirect Physiotherapeutic Treatment in TMD Subjects: A Randomized, Placebo-controlled Study

32

Dec 2016

NCT02602483a

Randomized, 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)

NCT02908568

Effect 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.  

References  

  1. Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: recommendations of the International RDC/TMD Consortium Network* and Orofacial Pain Special Interest Groupdagger. J Oral Facial Pain Headache. Winter 2014;28(1):6-27. PMID 24482784
  2. Ohrbach R, Turner JA, Sherman JJ, et al. The research diagnostic criteria for temporomandibular disorders. IV: evaluation of psychometric properties of the Axis II measures. J Orofac Pain. Winter 2010;24(1):48-62. PMID 20213031
  3. Schiffman E, Ohrbach R. Executive summary of the Diagnostic Criteria for Temporomandibular Disorders for clinical and research applications. J Am Dent Assoc. Jun 2016;147(6):438-445. PMID 26922248
  4. Manfredini D, Guarda-Nardini L. Ultrasonography of the temporomandibular joint: a literature review. Int J Oral Maxillofac Surg. Dec 2009;38(12):1229-1236. PMID 19700262
  5. Klasser GD, Okeson JP. The clinical usefulness of surface electromyography in the diagnosis and treatment of temporomandibular disorders. J Am Dent Assoc. Jun 2006;137(6):763-771. PMID 16803805
  6. Sharma S, Crow HC, McCall WD, Jr., et al. Systematic review of reliability and diagnostic validity of joint vibration analysis for diagnosis of temporomandibular disorders. J Orofac Pain. Winter 2013;27(1):51-60. PMID 23424720
  7. List T, Axelsson S. Management of TMD: evidence from systematic reviews and meta-analyses. J Oral Rehabil. May 2010;37(6):430-451. PMID 20438615
  8. Randhawa K, Bohay R, Cote P, et al. The effectiveness of noninvasive interventions for temporomandibular disorders: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Clin J Pain. Mar 2016;32(3):260-278. PMID 25924094
  9. Fricton J, Look JO, Wright E, et al. Systematic review and meta-analysis of randomized controlled trials evaluating intraoral orthopedic appliances for temporomandibular disorders. J Orofac Pain. Summer 2010;24(3):237-254. PMID 20664825
  10. Ivorra-Carbonell L, Montiel-Company JM, Almerich-Silla JM, et al. Impact of functional mandibular advancement appliances on the temporomandibular joint - a systematic review. Med Oral Patol Oral Cir Bucal. Sep 1 2016;21(5):e565-572. PMID 27475694
  11. Ebrahim S, Montoya L, Busse JW, et al. The effectiveness of splint therapy in patients with temporomandibular disorders: a systematic review and meta-analysis. J Am Dent Assoc. Aug 2012;143(8):847-857. PMID 22855899
  12. Zhang C, Wu JY, Deng DL, et al. Efficacy of splint therapy for the management of temporomandibular disorders: a meta-analysis. Oncotarget. Dec 20 2016;7(51):84043-84053. PMID 27823980
  13. Al-Ani MZ, Davies SJ, Gray RJ, et al. Stabilisation splint therapy for temporomandibular pain dysfunction syndrome. Cochrane Database Syst Rev. Feb 2004(1):CD002778. PMID 14973990
  14. Al-Ani MZ, Davies SJ, Gray RJ, et al. WITHDRAWN: Stabilisation splint therapy for temporomandibular pain dysfunction syndrome. Cochrane Database Syst Rev. Jan 04 2016(1):CD002778. PMID 26727210
  15. Häggman-Henrikson B, Alstergren P, Davidson T, et al. Pharmacological treatment of oro-facial pain - health technology assessment including a systematic review with network meta-analysis. J Oral Rehabil. Oct 2017;44(10):800-826. PMID 28884860
  16. Jung A, Shin BC, Lee MS, et al. Acupuncture for treating temporomandibular joint disorders: a systematic review and meta-analysis of randomized, sham-controlled trials. J Dent. May 2011;39(5):341-350. PMID 21354460
  17. Luther F, Layton S, McDonald F. Orthodontics for treating temporomandibular joint (TMJ) disorders. Cochrane Database Syst Rev. Jul 7 2010(7):CD006541. PMID 20614447
  18. Luther F, Layton S, McDonald F. WITHDRAWN: Orthodontics for treating temporomandibular joint (TMJ) disorders. Cochrane Database Syst Rev. Jan 07 2016(1):CD006541. PMID 26741357
  19. Manfredini D, Piccotti F, Guarda-Nardini L. Hyaluronic acid in the treatment of TMJ disorders: a systematic review of the literature. Cranio. Jul 2010;28(3):166-176. PMID 20806734
  20. Machado E, Bonotto D, Cunali PA. Intra-articular injections with corticosteroids and sodium hyaluronate for treating temporomandibular joint disorders: a systematic review. Dental Press J Orthod. Sep-Oct 2013;18(5):128-133. PMID 24352399
  21. Shi Z, Guo C, Awad M. Hyaluronate for temporomandibular joint disorders. Cochrane Database Syst Rev. Jan 2003(1):CD002970. PMID 12535445
  22. Goiato MC, da Silva EV, de Medeiros RA, et al. Are intra-articular injections of hyaluronic acid effective for the treatment of temporomandibular disorders? A systematic review. Int J Oral Maxillofac Surg. Dec 2016;45(12):1531-1537. PMID 27374020
  23. Shi Z, Guo C, Awad M. WITHDRAWN: Hyaluronate for temporomandibular joint disorders. Cochrane Database Syst Rev. Oct 8 2013(10):CD002970. PMID 24105378
  24. Liu Y, Wu J, Fei W, et al. There a difference in intra-articular injections of corticosteroids, hyaluronate, or placebo for temporomandibular osteoarthritis? J Oral Maxillofac Surg. Nov 8 2017. PMID 29182905
  25. Gorrela H, Prameela J, Srinivas G, et al. Efficacy of temporomandibular joint arthrocentesis with sodium hyaluronate in the management of temporomandibular joint disorders: a prospective randomized control trial. J Maxillofac Oral Surg. Dec 2017;16(4):479-484. PMID 29038631
  26. Manfredini D, Rancitelli D, Ferronato G, et al. Arthrocentesis with or without additional drugs in temporomandibular joint inflammatory-degenerative disease: comparison of six treatment protocols. J Oral Rehabil. Apr 2012;39(4):245-251. PMID 21999138
  27. Bjornland T, Gjaerum AA, Moystad A. Osteoarthritis of the temporomandibular joint: an evaluation of the effects and complications of corticosteroid injection compared with injection with sodium hyaluronate. J Oral Rehabil. Aug 2007;34(8):583-589. PMID 17650168
  28. Bertolami CN, Gay T, Clark GT, et al. Use of sodium hyaluronate in treating temporomandibular joint disorders: a randomized, double-blind, placebo-controlled clinical trial. J Oral Maxillofac Surg. Mar 1993;51(3):232-242. PMID 8445463
  29. Guo C, Shi Z, Revington P. Arthrocentesis and lavage for treating temporomandibular joint disorders. Cochrane Database Syst Rev. Oct 7 2009(4):CD004973. PMID 19821335
  30. Guo C, Shi Z, Revington P. WITHDRAWN: Arthrocentesis and lavage for treating temporomandibular joint disorders. Cochrane Database Syst Rev. Dec 16 2015(12):CD004973. PMID 26677172
  31. Rigon M, Pereira LM, Bortoluzzi MC, et al. WITHDRAWN: Arthroscopy for temporomandibular disorders. Cochrane Database Syst Rev. Dec 16 2015(12):CD006385. PMID 26677136
  32. Vos LM, Huddleston Slater JJ, Stegenga B. Lavage therapy versus nonsurgical therapy for the treatment of arthralgia of the temporomandibular joint: a systematic review of randomized controlled trials. J Orofac Pain. Spring 2013;27(2):171-179. PMID 23630689
  33. American Association for Dental Research (AADR). Science Policy: Temporomandibular disorders (TMD). 1996 (revised 2010, reaffirmed 2015); http://www.iadr.org/AADR/About-Us/Policy-Statements/Science-Policy#TMD. Accessed January 29, 2018.
  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.

Coding Section 

Codes Number Description
CPT 20605

Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa)

  21010

Arthrotomy, temporomandibular joint

  21116

Injection procedure for temporomandibular joint arthrography

  21050

Condylectomy, temporomandibular joint

  21060

Meniscectomy, partial or complete, temporomandibular joint

  21073

Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (i.e., general or monitored anesthesia care)

  21240-21243

Arthroplasty, temporomandibular joint code range

  29800

Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure)

  29804

Arthroscopy, temporomandibular joint, surgical 

  70328-70332

Radiologic exam of temporomandibular joint code range (including diagnostic X-rays, arthrograms) 

  70336

Magnetic resonance (e.g., proton) imaging, temporomandibular joint(s) 

  70350

Cephalogram, orthodontic  

  70355

Orthopantogram  

  97010

Application of a modality to 1 or more areas; hot or cold packs

  97024

Application of a modality to 1 or more areas; diathermy 

  97026

Application of a modality to 1 or more areas; infrared 

ICD-9 Procedure 76.5

Arthroplasty, temporomandibular joint, condylectomy of mandibular joint; meniscectomy 

  76.93-76.95

Manipulation of temporomandibular joint for reduction of fracture or dislocation 

  80.21

Arthroscopy 

  80.51

Discectomy 

  80.91

Arthrocentesis 

  87.12

Orthodontic cephalogram 

  87.13

Arthrogram, temporomandibular joint 

  87.16

Diagnostic X-ray of facial bones

  88.97 

MRI 

  93.35 

Heat therapy 

  93.39

Physical therapy 

 ICD-9 Diagnosis 524.60 

Temporomandibular joint disorders, unspecified 

  524.62 

Arthralgia 

  524.69 

Other specified temporomandibular joint disorders 

  524.7 

Other dentofacial anomalies 

  526.89 

Congenital anomaly (includes condylar hypoplasia/hyperplasia) 

  526.9 

Jaw disease 

  715.90 

Degenerative joint disease, spine 

  722.1-722.2 

Displacement, intervertebral disc code range 

  959.0 

Injury, jaw 

HCPCS  J7321-J7326 

Hyaluronan preparations for intra-articular injection, code range 

  S8948 

Application of a modality (requiring constant provider attendance) to one or more areas; low-level laser; each 15 minutes

 ICD-10-CM (effective 10/01/15) M26.00-M26.09 

Major anomalies of jaw size 

  M26.10-M26.19 

Anomalies of jaw-cranial base relationship 

  M26.50-M26.59 

Dentofacial functional abnormalities 

  M26.60-M26.69 

Temporomandibular joint disorders 

 

S03.0xxA-S03.0xxS 

Dislocation of jaw code range 

 

S03.4xxA-S03.4xxS 

Sprain of jaw code range 

ICD-10-PCS (effective 10/01/15) 

0R9C3ZZ, 0R9D3ZZ 

Drainage, temporomandibular joint, percutaneous, no device, code list 

 

0RBC0ZZ, 0RBD0ZZ 

Excision, temporomandibular joint, open, no device, code list 

 

0RBC4ZZ, 0RBD4ZZ 

Excision, temporomandibular joint, percutaneous endoscopic, no device, code list 

 

0RJC4ZZ, 0RJD4ZZ 

Inspection, temporomandibular joint, percutaneous endoscopic, no device, code list 

 

0RQC0ZZ, 0RQD0ZZ 

Repair, temporomandibular joint, open, no device, code list 

 

0RQC4ZZ, 0RQD4ZZ 

Repair, temporomandibular joint, percutaneous endoscopic, no device, code list 

 

0RQCXZZ, 0RQDXZZ 

Repair, temporomandibular joint, external, no device, code list 

 

0RRC0JZ, 0RRD0JZ 

Replacement, temporomandibular joint, open, synthetic substitute, code list 

 

0RSCXZZ, 0RSDXZZ 

Reposition, temporomandibular joint, external, no device, code list 

 

BN07ZZZ, BN08ZZZ, BN09ZZZ 

Plain radiography, temporomandibular joint(s), no contrast, code list 

 

BN070ZZ, BN071ZZ, BN07YZZ, BN080ZZ, BN081ZZ, BN08YZZ, BN090ZZ, BN091ZZ, BN09YZZ 

Plain radiography, temporomandibular joint(s), with contrast, code list 

 

BN39YZZ, BN39ZZZ 

Magnetic resonance imaging, temporomandibular joints, with or without contrast, code list 

 

F07J6BZ, F07J6CZ, F07J6DZ, F07J6EZ, F07J6FZ, F07J6GZ, F07J6HZ, F07J6UZ, F07J6YZ, F07J6ZZ 

Motor treatment, musculoskeletal system head and neck, therapeutic exercise, code list 

 

F07J7ZZ 

Motor treatment, musculoskeletal system –  head and neck, manual therapy techniques 

 

F08J5BZ, F08J5CZ, F08J5DZ, F08J5EZ, F08J5FZ, F08J5UZ, F08J5YZ, F08J5ZZ 

Activities of daily living treatment, musculoskeletal system – head and neck, wound management, code list 

Type of Service 

Medical 

 

Place of Service 

Outpatient/Physician’s office/Dentist’s office 

 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.  

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

08/01/2019 

 Annual review, no change to policy intent. Updating regulatory status, rationale and references.  

08/23/2018 

Annual review, no change to policy intent. Entire policy being revised to change the word"dysfunction" to "disorder".

08/23/2017 

Annual review, no change to policy intent. Updating background, description, regulatory status, rationale and references. 

08/02/2016 

Annual review, no change to policy intent. Updating rationale and references. 

08/12/2015 

Annual review, no change to policy intent. Physical therapy removed from list of investigational treatment. Updated background, description, related policies, rationale and references. Added coding.

07/29/2014

Annual review. Added Jint vibration analysis as investigational, removing low level laser therapy from this policy as it is addressed separately in CAM 20156. Added regulatory status and related policies. Updated rationale and references.


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