Event 3: Assessment and Treatment

EHR

Assessment

  • Right TMJ acute arthralgia causing Right ear pain, secondary to intensive tooth parafunction.
  • Right masseter myalgia, right sternocleidomastoid myalgia.
  • Likely Bruxism secondary to stressors, or paroxetine.
  • Occlusal traumatism secondary to bruxism.
  • New onset Major Depression.

Treatment Plan

General Guidelines

  • Explain findings to patient, reassure her.
  • Explain best available evidence for treatment and treatment options
  • Discuss with patient options and gather their preferences.
  • Devise treatment plan with patient preferences in mind along with self-care and patient education.

Specific

REC

  • Decrease day-time jaw activity
  • Jaw stretching + heat packs
  • Increase physical activity, walking.

RX

  • Soft Occlusal appliance (mouthguard).
  • Meloxicam 7.5 mg q Day – 10 to 14 days.

Other

  • Confer with Primary Care MD to discontinue Paroxetine and trial new SSRI or alternative anti-depressant.
  • Discuss referral to psychologist for depressive symptoms.
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