Event 8: Christine's Final Follow Up

 Pain Since Beginning Modified Treatment

Current Prescription Medication

Psychiatric Diagnosis

Christine says her psychiatrist just diagnosed her with bipolar disorder.

Christine's Final Follow Up Exam

Maximal Inter-incisal Opening

Christine's maximal inter-incisal opening
Maximal Inter-incisal Opening

Christine's maximal inter-incisal opening is 38 mm with no pain, no deviation on mandibular opening or limited excursions bilaterally.

Christine's TMJ Exam

Christine's TMJ exam
Christine's TMJ exam

Christine's TMJ exam shows her to be non-tender bilaterally with no click, pop, crepitus bilaterally.

Christine's Muscles of Mastication

Christine's muscles of mastication
Christine's muscles of mastication

Christine's muscles of mastication show:

  • Anterior Temporalis Muscle
    • Non-tender bilaterally without referred pain.
  • Masseter Muscle
    • Non-tender bilaterally
  • Masseter Muscle Origin
    • Mild on right

Final Assessment

  • Myalgia of right masseter muscle: mild.
  • Myofascial pain associated with anterior temporalis muscle: resolved.
  • Tension-type headache: resolved.
  • Parafunctional habit: appropriately managed.
  • Psychiatric disorder: appropriately managed.

Final Updated Treatment Plan

  • Wear occlusal appliance 8-12 hours/day while sleeping and during the day as feasible 
  • Continue with passive jaw stretches
  • Continue with psychiatric medications
  • follow-up with physician as per recommendations
  • Return to dental office in 2 months
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