History


Chief Complaint: This 74 year old female was referred because of complaint of progressive pain in the right face and limited jaw movement.

Medical History: Positive for breast cancer, arthritis, hypertension, and knee replacement; negative for blunt trauma to the jaw or face. No known allergies. Current medications included Zolpidem, HCTZ, Tramadol, and Prilosec. The patient slept 8 hours nightly and imbibed occasional caffeine.

Family Medical History: Heart disease, HBP, Cancer.

Review of Systems: Eye pain, GERD, headache, chewing difficulty right side.

Examination: Vitals: 165/90; Jaw Opening (ROM) 40mm with pain; maximum opening of 55 mm associated with right sided pain; crepitation bilateral L>R; occlusal contacts bilateral and stable; cranial nerves 2-12 within normal limits; myofascial: right mass and temporalis tender points; cervical within normal limits for her age; lateral capsular tenderness right TMJ

Intraoral: Probable geographic tongue; mild dental attrition

Radiography: See included CBCT images with specific emphasis on the right Temporomandibular joint.

Preliminary Impression: Arthromyalgia right TMJ

Final Diagnosis:
  1. OA Bilateral TMJ with loose body on left
  2. Masticatory Myalgia
  3. History of CA
      Treatment Plan: Plan diet changes; splint use pm's; symptomatic medications; topical anti-inflammatory medication

      This case is courtesy of Bradley Eli, DMD, MS
      Director, San Diego Headache and Facial Pain Center

      Assistant Professor, UCSD School of Medicine, Anes

      Dental School 1987 Temple University

      Post Doctoral education UCLA cert in Orofacial Pain, Masters in Oral Biology 1992