TMJ/TMD PATIENT HISTORY CASE STUDY

HISTORY OF A TYPICAL TMD PATIENT

TM is a 44-year-old white female with a history of having been in an automobile accident in which her car with hit from behind. She did not lose consciousness, but was experiencing immediate left jaw pain, left joint pain and clicking, both of which had not been present before the accident. She was taken to a local hospital where a cranial nerve screening exam was performed, neck X-ray were taken, Advil prescribed and then she was discharged.

Following the accident, TM saw her primary care physician who examined her without findings, except new onset jaw pain and TM joint pain and clicking. She was referred to her family dentist who did not treat TMD and referred her to an experienced TMD expert.

The TMD expert diagnosed TM with lefet TM joint synovitis, left TM joint anterior disc displacement with reduction, myofascial pain localized in the muscles of mastication most severely in the left masseter muscle. A TMD appliance to be worn day and night was made and 60% pain relief was achieved within 3 weeks. TM was then referred to physical therapy for myofascial release and the dentist performed two trigger point injections in the masseter muscle. Within 6 more weeks the pain was 90% alleviated with occasional exacerbations, a determination was made that TM achieved a medical endpoint, and the TMD appliance was used as at night only. Although there was 90% pain relief, TM was satisfied with treatment and had no trouble adjusting to minor intermittent pain.

HISTORY IS OF A SEVERE TMD PATIENT: THE WORST CASE SCENARIO

TJ is 33-year-old white female hit in left posterior jaw by a baseball while watching her son pitching in a little league baseball game. Within 24 hours, she experienced an increasing headache with pounding pain from the back of the neck to behind the eyes. She felt intense ear pain, jaw pain, difficulty opening the jaw as well as nausea and vomiting. She was taken to a local emergency room where a neurological exam was performed along with neck X-rays, and an MRI of the brain. The preliminary diagnosis by the emergency room physician was migraine and whiplash and possibly TMD. She was discharged wearing a neck collar and a prescription for naprosyn and advice to see her primary care physician and her dentist.

Because of the severity of the jaw pain TJ consulted first with her dentist who then referred her to an oral surgeon. Her chief complaint when presenting to the surgeon was severe jaw pain, headache, neckache and limited ability to open the jaw. Because of a clinical impression of a left disc displacement, the surgeon ordered an arthrotomogram that confirmed the disc displacement. The surgeon then ordered an appliance, physical therapy, and gave her a prescription for Valium. However, these treaTJents made her worse.

Because after 4 months of conservative treatment TJ was becoming impatient and irritable a new repositioning appliance was made, but this too made her worse. Then, once again, in response to TJ's desperation an arthroscopy which caused a major intensification of pain. At this point TJ's spouse called the surgeon to say that TJ was becoming less able to care for their children and was very depressed so as a last resort open joint surgery was performed.

TJ's pain persisted and once again intensified after surgery and PT, trigger point injections were ordered but without effect. A year after surgery with the pain as bad as even the Valium was increased to 5mg four times a day. She is also prescribed Vicodin but only 2 tablets a day, which had no effect.

Now TJ consults with a new TMD dentist who prescribes Elavil 25 mg at bedtime and Percocet four times per day. TheValium is decreased and a new appliance is made with poor results. TJ's mood swings increase and she is becoming less productive. She cries every day and her pain medications are increased to help control her pain.

TJ now has a limited TJ joint and cervical range of motion and requests repeated trigger point injections for temporary partial relief.

New imaging is ordered and the left TJ joint shows degenerative changes. There is now is experiencing right joint pain and her jaw deflects to the left. Her left posterior teeth hit slightly prematurely. An equilibration is done but the patient's symptoms worsen. A left joint injection with a steroid does not relieve the pain. Now Neurontin and Baclofen are prescribed, the Percocet is changed to morphine, and the dose of Elavil is increased with only partial benefit.

TJ's confusion is increasing but the medications are necessary to minimize her pain. Everyone is frustrated with TJ. A psychiatric consultation follows and TJ recounts her entire history and admits severe depression. The psychiatrist acknowledges that TJ has depression but feels the intense pain is valid and must be addressed. The psychiatrist also consults with TJ's husband who wants to explain the effect of TJ's pain on him. He states that he is tired of coming home and having to cook, clean and feed the children, that he has no social life or sex life. Because the psychiatrist states the pain is real further treaTJent is a total joint replacement is recommended. The total joint replacement fails to alleviate the pain and finally TJ is referred to a chronic pain program learn to live with pain.

Overview of TMJ / TMD | Causes of TMJ / TMD | Symptoms of TMJ / TMD
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