Hi. This patient finished braces in July 2014. 3 months after the braces were removed she complained of pain when eating on the right side. She felt a "bump" in her joing when she ate. She reported that her bite did not feel any different. She had a maximum opening of 45mm with no pops, clicks or deviation. There was tenderness to palpation over the right joint capsule. I gave her an aqualizer.

Her symptoms abated for about one year. Recently, she presented again with jaw pain and "cracking". She would wake up in the evening up to 3 times with pain and a "crack". Moving her jaw a certain way would send "screeching" pain into the left TMJ area. She reported that sometimes there would be pain at a certain point of opening. The pain was relieved if moved a "certain way". She has pain with chewing.

Clinical Exam:

Palpation: Left masseter: pain with score of 4 (of 10), Left SCM pain with score of 5.5. left joint pain level 1 when closed, left joint pain level 3 when moving.

Mx opening = 23mm with a "soft end feel"., right lateral 8mm , left lateral 8mm, Protrusive 5mm. The patient had pain with movement all three directions, especially protrusive. [image:1Angelica_Range.jpg]

Biting on a stick on the right side produced pain in the left joint and masseter areas. THEre was no pain when biting on the left side.

THere was no clicking or popping. Opening closing deviations did occur but they were inconsistent.

Provocation tests:

Loading in centric with a leaf gauge produced pain level of 5 on the left side. Pain quality considered "sharp".

Provocation tests: left lateral pain score of 5, right lateral pain score of 1, protrustion, pain score of 6. [image:1Angelica_Range.jpg]

She does not have fremitus or heavy anterior contacts.

I am having a hard time trying to determine if her issue is muscular or joint related, but I suspect it is both. I gave her an aqualizer since that worked last time and I advised her to take Aadvil for a week. Any help in what may be going on and what more I could do to figure it out would be helpful.

THanks,

Robert Nisson, DDS MSD