October 18, 2010

Myofacial Pain with Normal TMJ – Case Study

This is a 21 y/o/w/f who is the daughter of an existing patient who was up north in college and started to experience severe jaw pains.  She saw a dentist in the college town and he gave her a $26,000 treatment plan that included orthodontics, veneers and an occlusal guard.  Her father wanted a second opinion while she was down for Thanksgiving break. These notes were written 3 years ago and my note outline has improved since then. “How to Design a Carestream/Kodak PracticeWorks Dental Chart Note: Myofacial Pain note”. The bold text are actual chart notes and the plain text are my comments:

The patient has been given a preliminary JVA and TekScan to determine what is the cause of their facial pain.  JVA appears normal or is a complete closed lock with normal range of motion. Pt is experiencing what appears to be myofacial pain because the center of discomfort is not around the TMJs.  Explained to the patient that this is commonly caused by malocclusion and can be treated by a variety of means.  One is to correct the malocclusion with a TekScan series of appointments.  This is a set of three appointment to completely equilibrate both upper and lower archs into a harmonious occlusion to ease the muscle stress and therefore discomfort.  Another more popular way is to simply make a full arch hard occlusal guard that only mimics harmonious occlusion and is to be worn for life.  A combination of the two may be needed if the TekScan cannot achieve discomfort free muscles.  The patient was given a estimate for the TekScan series of appointment and will think about her treatment options.  NV re-eval

The left joint appears completely normal and the right has a click half way between the teeth coming together which is indicative of a eminence click.

We did a quick TekScan because the patient didn’t have enough time to come in for more evaluation because she was leaving in the morning and we were fitting her into our schedule at the last minute.  I found out the case was already post-Orthodontics and she was biting on the left side 79%.6 at 93.8% maximum force.  Her right masseter muscle was very sore but she had just taken 800mg Motrin and was feeling better.

The patient came back for Christmas break and was in extreme pain.  We started adjusting the heaviest interferences right away.

Right lateral

Left lateral


We had her come back 2 weeks later and she was feeling much better.  We re-check her and adjusted the bite some more because of relapse.

Maximum intrecuspation

Right lateral

Left lateral.

Below is the completed treatment note entered into the chart for her equilibration.

Reviewed health history (past Hx of painful right side of jaw.  Masseter on that side was very painful to palpatation, Maximum mouth opening 45.0 mm with no deflection from midline.

JVA normal with eminence click at maximium opening.

Initial Intercuspated Position taken, from appointment 11/21/07

Occlusion Time A-B increment 0.3215 sec

A Force    0 %,  B Force   94.8 %

Left   69.3 % vs.  Right    30.7 %,

Disclusion Time A-B increment 0.19 sec from 95% force


Right Excursion Recorded/Adjusted, Right Canine guidance noted,

Left Excursion Recorded/Adjusted, Left Canine Guidance noted,

Protrusive Recorded /Adjusted

Overall impression was that the the distal most teeth on the UL were in extreme occlusion to a point where she felt like she was not touching on her right side at all. Once adjusted through all the excursions she felt like she was biting the best she had ever bitten in her life.

Ending Intercuspated Position taken after appointment 1/3/08

Occlusion Time A-B increment 0.13 sec

A Force    0 %,  B Force    94.9 %

Left   45.3 % vs.  Right   54.7  %,

Treatment was tolerated well and masseter feels much better. Next Visit: Re-eval

It has now been 2 years post treatment and she has not had any replapse in pain or malocclusion.  She didn’t want to wear an occlusal guard because she felt so good she felt it was a waste of money.  This is one of about 50 cases that I’ve done without committing my patient to wearing a $1 piece of plastic between their teeth for the rest of their lives. I simply do not understand why more dentists are not treating their myofacial pain patients with the JVA/TekScan. “How to Design a Carestream/Kodak PracticeWorks Dental Chart Note: Myofacial Pain note”.