Temporomandibular joint (TMJ) dysfunction may be the result of congenital and developmental anomalies; fractures and dislocations resulting from trauma, internal derangement, or ankylosis (stiffening or fixation of a joint); or arthritic and neoplastic diseases.

Symptoms attributed to TMJ dysfunction are varied 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).

Medical and/or surgical intervention is considered medically necessary in the treatment of TMJ dysfunction as outlined under Policy Guidelines.

The following diagnostic procedures are considered medically necessary in the diagnosis of TMJ dysfunction:

• 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).

Cephalograms and pantograms should be reviewed on an individual basis.

The following diagnostic procedures are considered investigational in the diagnosis of TMJ dysfunction:

• Electromyography (EMG), including surface EMG;
• Kinesiography;
• Thermography;
• Neuromuscular junction testing;
• Somatosensory testing;
• Transcranial or lateral skull X-rays;
• Sonogram (ultrasonic Doppler auscultation);
• Intra-oral tracing or gothic arch tracing (intended to demonstrate deviations in the positioning of the jaws that are associated with TMJ dysfunction);
• Muscle testing;
• Standard dental radiographic procedures;
• Range of motion measurements;
• Computerized mandibular scan (this 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 TMJ dysfunction).

The following non-surgical treatments are considered medically necessary in the treatment of TMJ dysfunction:

• Intra-oral reversible prosthetic devices/appliances (encompassing fabrication, insertion, and adjustment);
• Pharmacological treatment (such as anti-inflammatory, muscle relaxing, and analgesic medications).

The following non-surgical treatments are considered investigational in the treatment of TMJ dysfunction, and benefits should be denied:

• 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;
• TENS (transcutaneous electrical nerve stimulation);
• PENS (percutaneous electrical nerve stimulation);
• Physical therapy, including diathermy, infrared, and heat and cold treatment, and manipulation.

The following surgical treatments are considered medically necessary in the treatment of TMJ dysfunction:

• 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 including, but not limited to, arthroplasties; condylectomies; meniscus or disc plication and disc removal when TMJ dysfunction is the result of congenital anomalies, trauma, or disease in patients who have failed conservative treatment.

The following surgical treatment is considered investigational, and benefits should be denied:

• Arthroscopy of the TMJ for purely diagnostic purposes.

BlueCard/National Account Issues

Plans may wish to review their contract language on the diagnosis and treatment of TMJ dysfunction to ensure that the contract language is consistent with the Plan’s medical policy on TMJ dysfunctions. Some contracts may exclude coverage for TMJ dysfunction.

Dental contracts frequently exclude the diagnosis and treatment of TMJ dysfunction. Services excluded may include, but are not limited to, orthodontics, equilibration of the teeth, dental X-rays, and dental prosthesis, whether performed by a dentist or a physician. Other Plans may limit TMJ diagnosis and treatment to only 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/psychological visits in relation to TMJ dysfunction, as 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 TMJ syndrome.

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

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

Claims may be received for the treatment of TMJ dysfunction with, but not limited to, the following diagnoses/symptoms:

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

A search of the literature was completed through the MEDLINE database for the period of January 1992 through April 13, 1995. The search strategy focused on references containing the following Medical Subject Headings:

– Temporomandibular Disease/Drug Therapy
 
– Temporomandibular Joint Diseases (including Rehabilitation, Radiotherapy, Iontophoresis, Kinesiography, Electromyography, Trigger Point Injections, and Tendon Injections)
 
– Temporomandibular Joint Therapy

Research was limited to English-language journals on humans.

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