G. Intraoral Status

• Maximal incisal opening at first visit was 42 mm (Figure 2.33).
• Slight deviation of jaw to right with mouth opening (Figure 2.34).
• Increased condylar movement of the left TMJ.
• Post-normal tooth relation on the left side.
• Stable occlusion.

H. Diagnosis/Diagnoses

Expanded DC/TMD

• Systemic arthritides.

DC/TMD

• Arthralgia left TMJ.

Other

• Juvenile idiopathic arthritis (JIA).

I. Additional Examinations and Findings

• TMJ MRI with contrast revealed: normal right TMJ; left TMJ with anterior flattening of condyle, small erosions, pannus anteriorly, and mild periarticular contrast enhancement (Figure 2.35).

J. Case Assessment

• Likely JIA as cause of TMJ pain, based on imaging and history of other joint pain.
• Idiopathic chondrolysis is in differential diagnosis, which may ultimately be JIA.
• TMD with orofacial pain as a cause of parafunctional activity is in differential diagnosis and could be a reason to insert behavioral and relieving treatment as a complement.
• TMJ arthritis in children also occurs in other rheumatic disorders (e.g., sarcoidosis, Sjögren’s, mixed connective tissue disease, dermatomyositis), but for this patient there were no signs/symptoms to suggest these diseases as the cause of her TMJ arthritis (Stoll and Cron, 2015).

K. Evidence-based Treatment Plan including Aims

• Stop progression of ongoing TMJ inflammation.
• Minimize TMJ pain associated with TMJ arthritis.
• Maintain mouth opening and function.
• Systemic anti-arthritis therapy, including biologic agents (e.g., TNF inhibitors) (Stoll et al., 2015).
• Intraarticular long-acting corticosteroids (Ringold and Cron, 2009).
• Oral functional appliances may help to reduce pain, improve jaw movement, and maintain normal mandible and mid-face growth in children with JIA when used routinely over several years (Portelli et al., 2014; Stoll and Cron, 2015).

L. Prognosis and Discussion

• Guarded prognosis in terms of TMJ arthritis in JIA as it remains a difficult-to-treat joint (Stoll and Cron, 2015).
• TMJ arthritis can progress (as noted on MRI) despite aggressive systemic therapy for JIA (Stoll et al., 2015).
• TMJ arthritis may or may not respond to systemic therapy or to intraarticular immunosuppression (corticosteroids or TNF inhibitors) (Stoll et al., 2015).
• Undertreated or unresponsive progressive TMJ arthritis in growing children can lead to micrognathia, mid-face growth disturbances, facial asymmetry, poor mouth opening, and TMJ pain at rest, or with activity (e.g., eating, speaking; Arabshahi and Cron, 2006).
• Over the following 2 years, she received intraarticular corticosteroids to her left TMJ on two occasions.
• In addition, her TMJ arthritis and JIA (other joints) were managed with systemic TNF inhibitors, eventually switch to co-stimulatory blockade (CTLA-4-Ig).
• Two years later, TMJ MRI showed normal right TMJ, left TMJ condyle flattening with erosions over the majority of the articular surface, bone marrow edema, 4 mm effusion, diffuse synovial thickening, increased pannus, and disc displacement anteriorly and medially (Figure 2.36).
• Her TMJ symptoms are markedly improved after therapy.

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