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Are Your Patients Asking About BOTOX® Treatment?

Author: Donald Tanenbaum DDS MPH - Board-Certified Orofacial Pain Specialist at New York TMJ & Orofacial Pain

Date: November 19, 2020

Many of you have inquired about whether there is any straightforward and easy-to-understand information about BOTOX® injections that would help your patients decide whether it is a treatment option they should consider for their TMJ/Facial Pain.

Therefore, I have put together a few conversation points that should be helpful to discuss with your patients.

  • BOTOX® Works By Reducing Muscle Contraction
    • After injected into muscles, BOTOX® reduces their ability to contract fully. When muscles are under the influence of BOTOX® for 3-4 months after it is injected, the force that they can exert is reduced. As a result, although the brain may be telling muscles to contract with normal force, that cannot happen as long as the BOTOX® is active.
    • Therefore, BOTOX® can be a part of the overall strategy to lessen muscle stiffness, spasm, and overactivity.
  • BOTOX® Can Relieve Pain
    • When BOTOX® is injected into muscles and causes muscle fibers to relax, less lactic acid and other pain-producing substances accumulate. As a result, nerve endings within the muscle tissues are less irritated and send fewer pain signals to the brain.
    • At the same time, BOTOX® also directly reduces the release of pain-producing chemicals associated with sensory nerve endings in the muscles.
  • BOTOX® Stays Where It’s Put
    • BOTOX®, after injected, typically stays where it is put. It does not roam throughout the body or spread to adjacent muscles – assuming the proper volume and techniques were used. While swelling and bruising can result, these consequences are often dependent on the clinician’s technique and the injections’ depth.
  • Where Is BOTOX® Injected?
    • To treat TMJ symptoms, BOTOX® is typically injected into the masseter and temporalis muscles. Less frequently, BOTOX® is injected in the lateral pterygoid muscles. This injection requires guidance technology to ensure the needle is placed in the correct location.
  • BOTOX® Is Often Not As Successful As Stand-Alone Therapy For TMJ
    • Although BOTOX® can help reduce muscle pain and the force of tooth contact, it alone does not commonly reduce inflammatory pain in the TM joints or predictably reduce clicking and locking of the TM joints that is associated with loose ligaments and changes in the position of the shock-absorbing disc.
    • Therefore, BOTOX® is not a replacement, but rather a complement, to other traditional therapies inclusive of medication, exercises, oral appliances, and physical therapy – particularly if joint instability and inflammation are present.
  • BOTOX® Is Not Typically A Once-And-Done Treatment For TMJ
    • Because BOTOX® is most commonly used for patients who have suffered for a long time due to both known and often unknown risk factors, one injection series typically will not, on its own, solve the problem.
    • Muscle-generated symptoms, which have been reduced and or even eliminated after the first injection session, can often return at variable degrees of intensity and thus require subsequent injections. This occurs most commonly when the risk factors leading to muscle pain have not been controlled or eliminated.
    • Repeat injections can be considered after 10-12 weeks have passed. Whether the same volume of BOTOX® is needed, or whether the same locations should be injected are determined based on patient symptoms and clinical findings.
  • Is BOTOX® a Good Substitute For Oral Appliance Therapy While Sleeping?
    • As you know, some patients are intolerant of oral appliances when they sleep due to their sensitive gag reflex. Others report the appliance makes them clench more, and their morning symptoms are worse. Many other patients find the appliances are damaged within a short period, and they can’t afford to purchase continued replacements. All these failures create a need for another option. BOTOX® can fill the void to some extent.
    • With BOTOX® on-board, clenching forces are less, but tooth contact will still occur, putting cusps at risk and not eliminating tooth wear. Without an appliance in place, ongoing injections every three to six months may be needed.
  • BOTOX® Can Slim The Jawline
    • Another way BOTOX® is being used is to cosmetically slim, bulky, overbuilt jaw muscles. Overbuilt jaw muscles (masseters) are sometimes the result of overuse (clenching and grinding during the day or night, gum-chewing, etc.) and/or facial profiles associated with some ethnic groups.
    • When injected repetitively, BOTOX® can change the composition of the jaw muscles by increasing the volume of collagen and fat and shrinking muscle fiber size. Therefore, a series of injections in the masseter muscles can slim a facial profile. Fortunately, this can be achieved without compromising jaw function or eating ability.
  • Is There Concern About Repetitive BOTOX® Injections?
    • Several ongoing studies are designed to determine if BOTOX®, by reducing muscle pull on the TM joints, could have an unfavorable influence on condylar bone density over time. At the moment, the results are inconclusive.
    • Because of these concerns, however, there should be at least a baseline x-ray of the TM joints and follow-up X-rays if BOTOX® injections are ongoing. Also, as noted previously, BOTOX® can change the composition of the jaw muscles when injected repetitively, increasing the volume of collagen and fat and shrinking muscle fiber size. These changes can create a hollow appearance of the jaw. This possibility must be discussed with the patient if injections continue over time.
  • BOTOX® Is Not For Kids
    • The use of BOTOX® in children and young teenagers should be avoided. Because the bone mass of the jaw joints has not fully matured at these young ages, reducing muscle pull around the TM joints as a result of BOTOX® injections is contraindicated.

Conclusion

BOTOX® as a therapeutic option is likely here to stay. Hopefully, these conversation points can help you guide your patients.

I invite your comments or questions.

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