When BOTOX? injection therapy stopped working…

During the past year, I had an opportunity to evaluate a 51-year-old patient who presented with an orofacial pain problem that seemingly had a muscle origin. Susan’s daily pain was focused in her teeth, temples, and masseter muscles and had been persistent for two years. Ongoing dental evaluations ruled out true tooth pathology and first line strategies to ease her masseter and temporalis pain because these methods had failed over a 6-month period of time.

In addition, NSAIDS and muscle relaxants provided no benefit. Oral appliances at night did not help and sometimes made her morning symptoms worse. Because Susan’s pain was accompanied by fatigue, sleep consultations had been pursued but did not reveal a sleep disorder. Her overall health was stable and she had been taking thyroid medication for over 15 years to address a hypothyroid condition.

After considering treatment options, a decision was made to try BOTOX? to address Susan’s pain symptoms and her sore and tender jaw muscles, which had led to limited and guarded jaw motion. As always, treatment was preceded by cautious expectation before judgment was rendered on success or failure.

A strategy was put into place to pursue three injection sessions – three months apart. We also encouraged surrounding the BOTOX? experience with eight hours of nightly sleep, 30 minutes of Tai Chi four to five days per week, ample daily hydration, limited caffeine, and a healthy dose of laughter as frequently as possible.

After each of the first two treatment sessions where BOTOX? was injected into the masseter, temporalis, and frontalis muscles, Susan experienced noticeable benefit and her pain rating score (VAS score) dropped from 8 to 2. In addition, her jaw motion improved from 30-32 mm to 40 mm with less effort and more fluidity.

With success seemingly achieved, we moved forward with the third injection hoping for further benefit, but no additional comfort was realized after the first week. After the second week, Susan’s pain levels unexpectedly increased to an acute level and her jaw motion returned to a sluggish, effortful 32 mm.

The typical questioning followed: “Did you inject the same stuff?” “Did you change the injection locations?” “Could we have over-treated the muscles?” “Am I ever going to experience that comfort again?”

Unfortunately, reassurances that everything would be fine and that we would figure it out only went so far. Susan, who had experienced real relief for the first time in two years, became a bit depressed as her pain escalation lingered. Concerned that she was losing her appetite because of the pain increase, we decided that she should visit her primary care physician. An evaluation led to a series of blood tests, which revealed that her thyroid levels had dropped significantly, in spite of the fact that six months prior they had been viewed as stable.?

Based on the recognized link between hypothyroidism and general pain-related muscle and joint symptoms — which included stiffness and achiness — we assumed this was why the BOTOX? results were inconsistent. In addition, because hypothyroidism can lead to peripheral neuropathy and associated pain, Susan’s level of intense suffering was now better understood.

With her thyroid levels regulated within a few short weeks, Susan regained most, but not all, of the pain relief that had been previously achieved with the first two BOTOX? injections. Her jaw motion also improved and, most importantly, so did her optimism.

Presently, Susan feels that the BOTOX? has indeed helped. She continues to follow all the other strategies that include more sleep, more exercise, more hydration, limited caffeine, and the pursuit of the moments and experiences that bring a smile to her face and laughter to her belly.

The moral of this story is clear:

When things do not go as expected when treating a pain patient, go back and reassess all potential risk factors in her medical, dental and social history that may be derailing an otherwise successful intervention.

In this case, the drop in Susan’s thyroid hormone levels was the clear culprit.

I welcome your comments.