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.