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Looking At Neurotoxins In A Different Light

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

Date: July 15, 2020

Over the course of the last several years, I’ve written many newsletters and patient blogs discussing the use and potential effectiveness of BOTOX® (neurotoxins) when dealing with TMJ and facial pain complaints.
In these commentaries, I often voiced my reluctance to offer BOTOX® (neurotoxins) as a first-line therapy when a patient’s suffering had, seemingly, been secondary to muscle-guarding and spasm. This was my bias because, for the most part, traditional treatment options predictably led to successful treatment outcomes.
With time on my hands during the recent quarantine, however, I had the opportunity to review the charts of patients who had not initially done well with what I thought would be an effective treatment. Many of these patients subsequently received BOTOX® injections and responded favorably. The question then became, what features of that patient’s profile could have been identified early on, prompting a different approach to early treatment efforts?
Before sharing one such patient profile, it is important to remember that BOTOX® (a neurotoxin) has the potential to address muscle and nerve-driven pain complaints by (A) Binding to motor neurons and inhibiting the release of acetylcholine and by (B) Reducing the release of pain-inducing neuropeptides by sensory nerves, respectively.
In essence, two very different types of pain-driving mechanisms can be tuned down with neurotoxins.
After a careful review of a number of patient charts, it became clear that many of those patients who failed first-line therapy directed towards muscles were probably misdiagnosed. Although clinically, their muscles appeared to be the culprits, the muscle pain and dysfunction evidenced was likely the result of a primary neuropathic pain origin.
With that realization in mind, the search for the neuropathic pain origin was all that remained to understand the symptom profile and clinical presentation. Potential suspects included a history of life traumas such as PTSD, chemo and radiation therapy, insomnia, eating disorders with purging, long-term use of stimulants such as Adderal, Strattera, Concerta, etc., event-associated orofacial traumas, and those specific to dental treatment inclusive of wisdom tooth extraction and implant placement.
All of the above have the potential to upset the trigeminal system leading to the complaint of pain.


Case Study: Brenda
Brenda, a 47-year-old female, presented this past year with a TMJ and orofacial pain history dating back three years following a ski accident and the onset of jaw pain. Despite some limited home care, her right-sided jaw tension and pain, temporalis headaches, and limited jaw motion persisted.
Prior to her ski accident, she had suffered some early life emotional traumas, which, when re-lived even prior to her accident, led to an emergence of jaw and face pain though typically short-lived. When recently coupled with the need to care for her aging mother who has dementia, Brenda’s pain had “taken over” her life.
Despite ongoing counseling with a therapist and home care for muscle pain, she, as noted, continued to struggle.
An examination revealed widespread and significant levels of tenderness on the right side over both the jaw and neck muscles. The joints themselves were not significantly tender. Jaw motion measured 31mm with effort. The application of a cold anesthetic spray (ethyl chloride), the ability to move to 39mm followed.
Brenda’s reported ongoing daytime clenching and tooth contact was evidenced by large and overdeveloped jaw muscles.
Despite her involvement in the treatment I advocated, including strategies to change daytime jaw overuse behaviors, muscle trigger point injections, eight physical therapy sessions, and a low dose tricyclic medication, Brenda’s symptoms did not budge. Palpation of the jaw muscles still prompted a high level of pain.
With first-line efforts exhausted, 100 units of BOTOX® were injected into the masseter and temporalis muscles. Within 48 hours, Brenda reported a substantial level of pain relief and her jaw opened wider with less effort. With at least 72 hours required for BOTOX® to actually impact muscle function, this level of relief had to be due to the impact of the BOTOX® on neuropeptide release by sensory nerves. A neuropathic mechanism was thus suspected of driving what appeared initially to be a dominant muscle problem.
As the impact of BOTOX® is time-dependent, maximum benefit was realized in about three weeks but began to creep back just prior to three months. This prompted a second and then third series of injections spaced three months apart until more consistent and lasting relief was reported.


As always, there is a moral to the story…
There is no substitute for a thorough history as it often reveals clues that are invaluable in the formulation of a diagnosis and making treatment decisions.
In this particular case, the patient’s history of both physical and emotional traumas and persistent pain was probably sufficient to suggest that somewhere along the line, the nerves encompassing the trigeminal system had become a dominant part of her suffering.
BOTOX® (a neurotoxin), therefore, could have been a reasonable option as first-line therapy.
I welcome your thoughts,
Donald Tanenbaum, DDS MPH

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