Patient presented to the dental OPD with a history of extraction done 5 days ago complaining of jaw pain.
Clinical examination was done:
- TMJ was examined for clicking sounds. It was present.
- Muscles (temporalis, masseter, medial pterygoid, sternocleidomastoid) were palpated for signs of discomfort. They were tender on the right side.
- Probing was done for checking pockets. There was bleeding on probing. Pockets were present. (if probing depth is greater than 3mm, it is considered not normal and a pocket is present.)
- Patient was anxious and not able to locate the pain
Diagnosis:
- Post extraction pain
- TMPDS due to stress and disrupted sleep
- Gingivitis
Management:
- Patient was advised a pressure massage of the right temporalis and masseter muscle
- Muscle relaxant and painkiller were prescribed: Nuberol Forte 1 tab OD for 7 days, Nims 100mg 12 hourly for 7 days.
- Patient was demonstrated how to do jaw exercises. Passive exercises (when pain is acute): mouth opening, mouth closing, protruding the jaw, retruding the jaw. These need to be repeated 5 times thrice a day.
- Patient was advised scaling after the symptoms subside
This case was done at OMFS Dept. Farooq Hospital Westwood Branch, Lahore.