Clinical Notes

TMJ Consult​

COVID-19 SCREENING
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Patient was pre-screened per OS protocol prior to appointment.
Patient was additionally screening via phone when they arrived outside the practice and temperature was checked. 
COVID-19 Consent was completed in addition all OS paperwork . Patient signature was verified.
Room was disinfected using Super Sani-Cloth Germicidal Disposable Wipe (EPA Reg # 9480-4 ) techniques per manufactures protocols, followed by Clorox® Clean-Up® Cleaner + Bleach (EPA Reg. No. 5813-21) Spray and room dry. Room was verified by the other assistant for completion via COVID-19 Room disinfection checklist.
Patient also rinsed with 1.5% hydrogen peroxide for 30 second 


​​Progress Note
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Patient seen at the request of the office general dentist for atypical/TMJ facial pain

Patient reports  (+ present  - abscent)

headaches +           migraine +        Popping noise R+ L+

Jaw Locking +         Clenching +      Stress +

Prior treatment options : xxxxxxxx


Review of Symptoms
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Facial pain                    Yes                                   Snoring                        No
Pain with chewing          No                                    Bleeding Gum             No
Lumps in the neck          No                                    Difficulty Swallowing   No
Lumps in face                 No                                    Pain Swallowing          No
Shortness of breath        No                                    Limited Opening         No
TMJ pain                        Yes                                    Sinus Pain                   No
Dry Mouth                      No                                    Chills                            No
Fever                              No                                    Nausea / Vomiting       No
Hoarseness                     No

Past Medical History
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See med history from (in Document Center)

​​Past Surgical History
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See med history form (in Document Center)

​​Medication
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See med history form (in Document Center)


Allergies
------------
See med history form  (in Document Center)

Social History
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Smoking – See med history form  (in Document Center)
Alcohol - See med history form  (in Document Center)
Drugs - See med history form  (in Document Center)

​CLINICAL EXAMINATION:
Extraoral, Head and Neck exam:
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Constitutional: general appearance of patient 
No extraoral swelling or erythema
Parotid and submandibular glands soft, nonpainful to palpation bilaterally
No lesion noted on facial skin
Facial palpitation exam reviews no swelling or no lymphadenopathy
CN V1, V2, V3, CN VII intact bilaterally
No neck masses noted
Thyroid midline with no evidence of any swelling
Musculoskeletal: TMJ joint tenderness.

                            Popping R   and  L

                            Myofacial (masseter temporalis tenderness and hypertrophy)

                            Neck / Shoulder tenderness
Maximum mouth opening within normal range

Intraoral Soft Tissues:
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Clear saliva extruded from bilateral Wharton's and Stenson's ducts
Tongue soft and non-tender with no apparent lesions
Buccal mucosa without lesions bilaterally
Hard palate, soft palate, and pharynx are within normal limits no pathology visualized
Floor of mouth without an evidence of pathology
Gingival tissues are pink, firm, and stippled and without erythema or swelling

​Lateral pterygoid tenderness bilaterally

Dentition:
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Normal complimentary maxillary and mandibular teeth


Radiographic examination:
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Panorex reviewed demonstrates
No bony pathology.  


ASSESSMENT / PLAN / RECOMMENDATION
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Patient referred for TMJ/Facial Pain

Myofacial  Component : Present     Neck Component : Present

TMJ Disc Component   : Present 

Bone Component : Absent 

Wilks Classification :   

RECOMMENDATIONS

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Facial CT / MRI without contrast

Mouth Guard - impressions taken

BOTOX Injection - 200 Units

Joseph Krajekian DMD, MD, FAAOMS, DABOMS

(C) 2020 Dr. Joseph Krajekian

Telephone :  (440) 646-0597 Office 

                     (888) 774-7773 Answering Service

Fax #         :  (888) 774-7970