My Latest Insights on Botox & TMD/Oral Nerve Pain

The number of patients in our office treated with Botox has increased over the past year. This has enabled us to gain some additional insights into what to look for in determining if a patient is a good fit for this specific treatment. Here are our top 6 insights:

Insight 1: Botox is not a first line treatment offering

Botox therapy is not a first-line treatment offering for a patient who has a relatively new TMJ problem and who has not yet had basic intervention to address muscle spasm, tightness, and pain.?First line treatment continues to be dictated by a careful evaluation which will most of the time identify why a patient’s symptoms are present.

If the reasons for the muscle/pain problems are not identified, eliminated or reduced, Botox will likely not produce the desired goals.

If daytime habits, postures, behavioral tendencies and labored breathing patterns that often fatigue jaw/neck muscles are not addressed, Botox will be an expensive and disappointing option. When nighttime clenching or grinding tendencies produce morning symptoms, then the first course of action has traditionally been to use an oral appliance design (based on the perceived origin of the bruxism activity), as this option continues to provide substantial relief for countless patients.

Additional first line treatment efforts that produce predictable results when muscle symptoms are the result of overuse activities and sleep bruxism include medications (when plausible), at-home jaw/neck/ breathing exercises, meditation, biofeedback, cognitive behavioral therapy, dietary changes, or all of the above. Beyond these basic efforts, muscle injections or dry needling of muscles would be next in line along with visits to a physical therapist, chiropractor, or osteopath who would work to promote muscle comfort.

If these therapies, which work directly on muscle tissue, don’t at least provide transient benefit, Botox would be an unpredictable next option.

Insight 2: Not all muscle pain is the same

There are countless times when muscles hurt even when not fatigued or strained by daytime or nighttime patterns of overuse.?An examination of these patients often reveals very tender muscles, but no evidence of muscle hypertrophy, which would be expected if muscles are overworked mechanically on a frequent basis. Therefore, muscles can also ache as a result of underlying autoimmune disorders, systemic inflammatory disorders,?insomnia, co-morbid problems, irritable bowel disease (IBS), obstructive sleep apnea (OSA), primary anxiety disorders, persistent emotional upset, PTSD (domestic reasons) and an infinite number of other cause.

That’s why there is no substitute for a careful history and understanding of the patient who is attached to the reported symptoms. The use of Botox in these scenarios will likely not be helpful as the muscle pain is probably being generated by centralized pain mechanisms that don’t respond well to peripheral treatments in specific muscles.

Insight 3: Oral appliance use with Botox

In a patient where sleep bruxism (clenching and grinding) is associated with morning symptoms of muscle pain or tightness, and/or joint noises, locking, or pain despite the consistent wearing and tolerating of an oral appliance, the use of Botox seems to improve symptoms to some degree, but only when the appliance is worn on a continued nightly basis.

At this point in time, we have seen morning symptoms reduce after Botox, but continued appliance wear appears to be an important obligation. Botox, in this case, is viewed as an important complementary treatment to enhance the ability of the appliance to dampen the impact of bruxism on the muscles and joints. Repeated Botox injections will likely be needed.

Insight 4:?Botox use when an oral appliance is not tolerated

For a patient who cannot tolerate an oral appliance (gagging, dry mouth, increase of morning symptoms) but finds that in the morning their teeth are “plastered together” Botox appears to have meaningful benefit in terms of symptom reduction. This usually occurs after the second or third administration.

Studies where Botox is injected only into the masseters have indicated that the temporalis muscles are still fully engaged in bruxism activity. This result has clarified the belief that bruxism activity is a brain-driven event and therefore cannot be stopped by peripheral therapies inclusive of Botox.

The improvement that results is likely due to less morning masseter fatigue and a drop in the concentration of the byproducts (lactic acid) of muscle overuse. Repeated Botox injections will likely be needed.

Insight 5: Facial aesthetics

For a patient with bulky jaw muscles and a square jaw profile due to excessive development, Botox has been shown to consistently change facial aesthetics. A flatter jaw profile can be obtained after two to three injection sessions. This change in profile is obtained without altering chewing capacity, speech, or smiles.

Insight 6: Oral nerve pain problems

Botox appears to have benefit with a number of oral nerve pain problems that we see. When sharp/aching pain is present in gum tissue, at extraction sites, and at other orofacial sites, the use of small quantities of Botox has been shown to decrease episodes of sparking nerve pain and/or continuous nerve pain.

Nerve pain in the face or inside the mouth is often due to excessive electrical discharge from the trigeminal nerve. The origins can be underlying medical prompters and/or traumas. At times, specific trigger zones cause the nerve pain to fire. Administering Botox in these trigger zones appears to provide benefit for sufferers who do not respond or cannot tolerate oral medications. Ongoing research points to the ability of Botox to reduce the release of pain-producing chemicals (neuropeptides) as the reason for symptom reduction

In summary, the use of Botox in the management of TMJ and oral nerve pain problems continues to gain support. The important lesson here is that careful assessment remains the key to making treatment decisions that have positive outcomes.

I welcome your thoughts.