Pain Since Beginning Modified Treatment
Current Prescription Medication
Psychiatric Diagnosis
Christine says her psychiatrist just diagnosed her with bipolar disorder.
Christine's Third Follow Up Exam
Maximal Inter-incisal Opening
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Christine's maximal inter-incisal opening is 36 mm with mild pain in right masseter muscle, no deviation on mandibular opening or limited excursions bilaterally.
Christine's TMJ Exam
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Christine's TMJ exam shows her to be non-tender bilaterally with no click, pop, crepitus bilaterally.
Christine's Muscles of Mastication
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Christine's muscles of mastication show:
- Anterior Temporalis Muscle
- Non-tender bilaterally without referred pain.
- Masseter Muscle
- Mild on right
- Masseter Muscle Origin
- Mild on right
Third Assessment
- Myalgia of right masseter muscle: improved.
- Myofascial pain associated with anterior temporalis muscle: resolved.
- Tension-type headache: significantly improved.
- Parafunctional habit: partially managed.
- Psychiatric disorder contributing to orofacial pain condition: managed by psychiatrist.
Third Updated Treatment Plan
- Recommend custom-made occlusal appliance
- Dental impression completed for maxillary appliance
- Continue gentle passive jaw stretches
- Continue with current medications
- Return to office in 3 weeks
- Consultation with psychiatrist and primary care physician
Custom-Made Occlusal Appliance
Christine had a custom-made occlusal appliance created to help with her parafunctional habit of grinding/clenching.
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Consultation with Christine’s Dentist, Primary Care Physician, and Psychiatrist
Christine's dentist, primary care physician and psychiatrist consulted together to discuss Christine's case.
