This is part one of a three-part series where I discuss the utility of BOTOX® and other neuromodulators – the science and insights from treating patients at our Orofacial Pain practice.
In recent years, I’ve written numerous articles on the utility of BOTOX® and other neuromodulators to address orofacial pain and jaw disorders. In fact, this is the seventeenth piece I’ve written on the topic for our practice’s website alone!
While we certainly had requests for BOTOX® injections at our Orofacial Pain practice in the past, now we have daily encounters with patients asking about BOTOX® injections for what they perceive as muscle pain due to TMJ.
The increase in patients and the resultant outcomes inspire me to keep sharing our insights on the role of BOTOX® in this specific area of pain management with you.
BOTOX®s Journey To Becoming A Household Word
The journey began against the backdrop of significant public and medical interest sparked by a 2017 Time Magazine cover story, “How BOTOX® Became the Drug That is Treating Everything.” This article highlighted the newly expanded applications of BOTOX® beyond migraine and opened new avenues for treating various pain conditions.
The 2017 article states that we can “expect doctors to keep pushing the boundaries of BOTOX®’s applications–sometimes in the name of medical progress and sometimes with remarkable results.”
Fast forward to today, along with FDA approval still being specific to migraines and dystonia, BOTOX® is being utilized to treat other conditions, such as trigeminal neuralgia, post-herpetic neuralgia, and the complex domain of temporomandibular disorders and bruxism.
The most common request for BOTOX® at our practice comes from patients who’ve made an appointment to receive treatment for what they perceive to be muscle pain in their face and jaw. Many already have received a variety of treatments (including BOTOX®, while others are investigating their treatment options for the first time.
The collective expressions of discomfort below do suggest a muscle-centric issue. Yet, the persistence of pain, despite previous treatment, often including BOTOX® injections, indicates a need to understand pain manifestations more deeply.
What Patients Tell Us
We spend a lot of time talking with our patients when they first visit our practice. They typically recount their suffering in one or more of these ways:
- “My jaw is sore and never relaxed…this is where I hold my tension.”
- “My face always aches and feels tight.”
- “I feel like I have a headache in my face.”
- “It hurts just to open my mouth, so I don’t.”
- “When I wake up, my teeth are plastered together, and I have pain in my jaws and temples.”
- “I wear a night guard, but it doesn’t help my morning pain. Sometimes it makes it worse!”
- “My teeth always hurt because I’m clenching them, and I can’t stop.”
The Four Categories of Pain, Defined
In order for us to appreciate what is causing such suffering in these “hard-to-get-better cases,” it’s necessary to first dive into the definitions of the four categories of pain:
1. Nociceptive or Somatic PainDefined as a more or less localized sensation of discomfort, distress, or agony resulting from the stimulation of specialized nerve endings (nociceptors), often associated with recognizable tissue injury or pathology and always accompanied by inflammation.
Muscle pain is a type of somatic pain always accompanied by inflammation, which dissipates as tissue healing occurs. The inflammation is a component of what we call peripheral sensitization and is the initiating component of the healing process.
2. Neuropathic Pain
Defined as pain due to abnormalities in neural structures, not in the somatic tissues where the pain is felt. The pain essentially comes from within the nervous system, which gives rise to pain in the absence of tissue injury and inflammation. I often refer to it as a circuit malfunction due to nerve damage.
As neuropathic pain continues, there is an increase in the excitability of neurons in central nociceptive pathways (central nervous system) and a decrease in the activation threshold of peripheral nociceptors. This is called central sensitization.
3. Nociplastic Pain
Defined as pain that arises despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors. Since nociception is essentially an unpleasant sensation, and a sensation is a brain interpretation, I call nociplastic pain brain opinion pain.
What can make the brain a wrong or inaccurate opinion-maker may well be influenced by this fourth category of pain.
4. Neuroimmune Pain
Defined as pain caused by the interaction between the nervous and immune systems. When glia, the surveillance cells of the immune system, are upset and activated, they communicate to the CNS through nerve pathways. The net effect of this relationship is that pain can be amplified and spread beyond what is expected based on examination findings or the history reported.
What is well understood is that glial cells can be excited and upset, for example, by a virus or the introduction of new medications that make people feel sick. However, glial cells can also be upset by less well-defined influences such as poor sleep, ongoing medical and social stressors, life trauma, persistent gastrointestinal problems, etc. Understanding the origin of the upset and mitigating its influence can, therefore, be difficult.
Conclusion
With such complexity and variability encompassing the pain experience, the question is, “What is the likelihood that BOTOX® can be a valuable therapeutic tool in treating Orocial Pain?” This is what I cover in Part 2.
To our colleagues: Your insights, reflections, and experiences are eagerly sought as we dig deep into this topic. Feel free to comment below with your thoughts.
*In this newsletter, ”BOTOX®” serves as a proxy to include all members of the neuromodulator family.
