Severe tmj issues

Hi Sandra,   I hope  this e-mail find you doing well.  I don’t know if you remember me, but I attended your workshop in Chicago in August 2008. I have a patient that was referred to me by a colleague and I was hoping that you might be able to help me. My colleague did the initial evaluation and referred her to me because she was unsure of what to do about recommending therapy.  The patient is a 38 year old female who was referred by her orthodontist — she is getting braces in a few weeks.  The issue that concerns me is that she has chronic TMJ, for which she wears a guard on her bottom teeth all the time except when eating.  She experiences muscle spasms  and is limited in opening her mouth wide. When closing her mouth, she jaw shifts like an “s”.  She sees a regular dentist for treatment of her TMJ. She says that he said that she may have been born with one side of her muscle shorter than the other.  She periodically receives massage therapy for pains in her neck and shoulder, and craniosacral therapy for her TMJ. She has seen a specialist for the TMJ in the past, but reported that he had done all he could for her and she no longer sees him.  She experiences pain especially in the evening. She demonstrates anterior tongue portruction when swallowing and her lingual resting position was anterior putting pressure against her front teeth.  Trial exercises given to the patient resulted in some pain and tremors on her left side.  My experience is limited with patients who have such severe TMJ, and I wanted to get your input, if possible, about whether or not to recommend therapy or to wait for her braces to begin t correct her malocclusion, etc.  I certaintly don’t want to do anything that would further hurt her or cause pain and didn’t know if there were some recommendations you could share. She really wants to go ahead with the therapy since it was recommended by her ortho. Thanks so much for your help, D    

This woman has a serious issues (or issueS) and the first rule is that nothing we do should cause any discomfort at all.  You mentioned trial exercises and I assume you meant exercises that you tried with her.( Your wrote: Trial exercises given to the patient resulted in some pain and tremors on her left side.)      If you can maximize her with proficiency exam #1 and address the lingual posture without causing any discomfort, that would be where I would start.  Also, be certain you explain to her that our job is not to solve TMJ problems, but sometimes as a result of orofacial myology training, some patients report some relief.       Be sure that you, personally, have done a thorough orofacial exam rather than relying on the results of your colleague, unless your colleague has also studied orofacial myology and is familiar with the areas we covered on the exam.      Let me know how this patient is doing   My best, Sandra