Description
Temporomandibular joint (TMJ) dysfunction causes pain and dysfunction in the jaw joint and muscles controlling jaw movement. Symptoms may include jaw pain, masticator muscle stiffness, limited movement or locking of the jaw, clicking or popping in jaw joint when opening or closing the mouth, and a change in how the upper and lower teeth fit together. The cause of the condition is not always clear but may include acute or chronic trauma to the jaw or temporomandibular joint, e.g., grinding of teeth, clenching of jaw, or impact in an accident.

Osteoarthritis or rheumatoid arthritis may also contribute to the condition.

Etiologies of TMJ dysfunction (TMD) include intra-articular (intracapsular) and extra-articular (extracapsular pathology). Intra-articular (intracapsular pathology), such as disc displacement and coexisting osteoarthritis or degenerative joint disease, is considered the most common cause of serious TMJ pain and dysfunction and the most likely to be treated surgically. Extra- articular (extracapsular pathology) includes musculoskeletal (bone, masticatory muscles and tendons) and central nervous system/peripheral nervous system.⁶

Imaging can assist in the diagnosis of TMD when history and physical examination findings are equivocal. The initial study should be plain radiography (transcranial and transmaxillary views) or panoramic radiography when there is recent trauma, dislocation, malocclusion, or dental infection.² Ultrasound is an inexpensive and easily performed imaging modality that can also be used to evaluate the TMJ.⁷ CT is useful to evaluate the bony structures of the TMJ when there is suspicion of bony involvement (i.e., fractures, erosions, infection, invasion by tumor, as well as congenital anomalies).1 Magnetic resonance imaging (MRI) has the highest sensitivity, specificity, and accuracy in the evaluation of temporomandibular joint dysfunction and provides tissue contrast for visualizing the soft tissue and periarticular structures of the TMJ.
 
Conservative care for TMD includes patient education, self-care, behavioral modification, cognitive behavioral therapy/biofeedback, medication, physical therapy, and occlusive devices. Medications include NSAIDS and muscle relaxants and in chronic cases, benzodiazepines, or antidepressants. There is lack of high-quality evidence and uncertainty about the effectiveness of manual therapy and therapeutic physical therapy in treating TMJ dysfunction.⁸ The use of occlusive splints is thought to alleviate some of the degenerative forces on the TMJ which may be helpful in patients with bruxism or nocturnal teeth clenching. Preferred devices are unclear from the literature and dental consultation is required.² In systematic reviews, there has been short-term benefit observed from splinting but no clear role in the overall long-term treatment of TMD patients.^9,10
 

GENERAL INFORMATION

It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.
 

INDICATIONS FOR TEMPOROMANDIBULAR JOINT (TMJ) MRI

Policy
TEMPOROMANDIBULAR JOINT (TMJ) MRI is considered MEDICALLY NESSARY for the following indications: 

For evaluation of temporomandibular joint dysfunction (TMD) with suspected internal joint derangement with:^1,2,3

• Persistent symptoms of facial or jaw pain, restricted range of motion, pain and/or noise with TMJ function (i.e., chewing) AND
• Conservative therapy with a trial of anti-inflammatory AND behavioral modification* has been unsuccessful for at least four (4) weeks

*Behavioral modification includes patient education, self-care, cognitive behavior therapy, physical therapy, and occlusal devices. Muscle relaxants can be used for spasm.

Note: X-ray should be the initial study if there is recent trauma, dislocation, malocclusion, or dental infection

For evaluation of juvenile idiopathic arthritis (JIA)^3,4

Abnormal initial X-ray or ultrasound needing additional imaging¹

Pre-operative evaluation in candidates for orthognathic surgery
 
Post-operative evaluation5

• A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

Other Indications
Further evaluation of indeterminate findings on prior imaging (unless follow up is otherwise specified within the guideline):

• For initial evaluation of an inconclusive finding on a prior imaging report that requires further clarification
• One follow-up exam of a prior indeterminate MR/CT finding to ensure no suspicious interval change has occurred. (No further surveillance unless specified as highly suspicious or change was found on last follow-up exam.)
   

All other uses of this technology are investigational and/or unproven and therefore considered NOT MEDICALLY NECESSARY. 

References 

1. Bag AK, Gaddikeri S, Singhal A, et al. Imaging of the temporomandibular joint: An update. World J Radiol. Aug 28 2014;6(8):567-82. doi:10.4329/wjr.v6.i8.567
2. Gauer RL, Semidey MJ. Diagnosis and treatment of temporomandibular disorders. Am Fam Physician. Mar 15 2015;91(6):378-86.
3. Petscavage-Thomas JM, Walker EA. Unlocking the jaw: advanced imaging of the temporomandibular joint. AJR Am J Roentgenol. Nov 2014;203(5):1047-58. doi:10.2214/ajr.13.12177
4. Granquist EJ. Treatment of the Temporomandibular Joint in a Child with Juvenile Idiopathic Arthritis. Oral Maxillofac Surg Clin North Am. Feb 2018;30(1):97-107. doi:10.1016/j.coms.2017.08.002
5. Hoffman D, Puig L. Complications of TMJ surgery. Oral Maxillofac Surg Clin North Am. Feb 2015;27(1):109-24. doi:10.1016/j.coms.2014.09.008
6. American Society of Temporomandibular Joint Surgeons. Guidelines for diagnosis and management of disorders involving the temporomandibular joint and related musculoskeletal structures. Cranio. Jan 2003;21(1):68-76.
7. Tu KH, Chuang HJ, Lai LA, Hsiao MY. Ultrasound Imaging for Temporomandibular Joint Disc Anterior Displacement. J Med Ultrasound. Apr-Jun 2018;26(2):109-110. doi:10.4103/jmu.Jmu_18_18
8. Armijo-Olivo S, Pitance L, Singh V, Neto F, Thie N, Michelotti A. Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders: Systematic Review and Meta-Analysis. Phys Ther. Jan 2016;96(1):9-25. doi:10.2522/ptj.20140548
9. Ebrahim S, Montoya L, Busse JW, Carrasco-Labra A, Guyatt GH. The effectiveness of splint therapy in patients with temporomandibular disorders: a systematic review and meta-analysis. J Am Dent Assoc. Aug 2012;143(8):847-57. doi:10.14219/jada.archive.2012.0289
10. Kuzmanovic Pficer J, Dodic S, Lazic V, Trajkovic G, Milic N, Milicic B. Occlusal stabilization splint for patients with temporomandibular disorders: Meta-analysis of short and long term effects. PLoS One. 2017;12(2):e0171296. doi:10.1371/journal.pone.0171296

Coding Section 

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 Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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

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