Botulinum Toxin for Frontline TMJ Syndrome and Dental

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1 CE credit
This course was
written for dentists,
dental hygienists,
and assistants.
Botulinum Toxin for
Frontline TMJ Syndrome
and Dental Therapeutic
Treatment
A Peer-Reviewed Publication
Written by Louis Malcmacher DDS MAGD
Abstract
This article will demonstrate how the
use of botulinum toxin is integrated
into daily dental treatment in a number
of disciplines. Non-surgical, minimally
invasive treatment of the muscles of the
head and neck is essential for frontline
TMJ and myofascial pain therapy as well
as treatment of bruxism, removable
prosthodontics, orthodontics, periodontics, and implant therapy.
Educational Objectives:
At the completion of this course, attendees will be able to:
1. List the most important and potentially useful concepts
in the use of botulinum toxin in the treatment of TMJ and
myofascial pain.
2. Identify whether a patient may be a good candidate for
the different treatment options for the use of botulinum
toxin for myofascial pain.
3. Describe current concepts in the use of botulinum toxin in
the oral and maxillofacial areas.
Author Profile
Louis Malcmacher DDS MAGD is a practicing general dentist
and an internationally known lecturer and author known for
his comprehensive and entertaining style. Dr. Malcmacher is
president of the American Academy of Facial Esthetics www.
FacialEsthetics.org . You can contact him at 800 952-0521 or
email [email protected] His website is www.CommonSenseDentistry.com where you can find information about
his hottest topics schedule, live patient Frontline Myofascial Pain
training, Botox and dermal fillers training, download his resource
list, and sign up for a free monthly e-newsletter.
Author Disclosure
Dr. Malcmacher is president of the American Academy of Facial
Esthetics.
Go Green, Go Online to take your course
Publication date: May 2013
Expiration date: Apr. 2016
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“ThiscoursemeetstheDentalBoardofCalifornia’srequirementsfor1unitofcontinuingeducation.”
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AcademyofGeneralDentistry.Theformalcontinuingdentaleducationprogramsofthis
programproviderareacceptedbytheAGDforFellowship,Mastershipandmembership
maintenancecredit.Approvaldoesnotimplyacceptancebyastateorprovincialboardof
dentistryorAGDendorsement.Thecurrenttermofapprovalextendsfrom(11/1/2011)to
(10/31/2015) Provider ID# 320452.
This educational activity was developed by PennWell’s Dental Group with no commercial support.
This course was written for dentists, dental hygienists and assistants, from novice to skilled.
Educational Methods: This course is a self-instructional journal and web activity.
Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or
services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or
third party has had any input into the development of course content.
Requirements for Successful Completion: To obtain 1 CE credit for this educational activity you must pay the
required fee, review the material, complete the course evaluation and obtain a score of at least 70%.
CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with
products or services discussed in this educational activity. Heather can be reached at [email protected]
Educational Disclaimer: Completing a single continuing education course does not provide enough information
to result in the participant being an expert in the field related to the course topic. It is a combination of many
educational courses and clinical experience that allows the participant to develop skills and expertise.
Image Authenticity Statement: The images in this educational activity have not been altered.
Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and
represents the most current information available from evidence based dentistry.
Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from
the data and information contained in reference section. The research data is extensive and provides direct benefit to
the patient and improvements in oral health. Registration: The cost of this CE course is $20.00 for 1 CE credit.
Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full
refund by contacting PennWell in writing.
Educational Objectives
At the completion of this course, attendees will be able to:
1. List the most important and potentially useful concepts
in the use of botulinum toxin in the treatment of TMJ and
myofascial pain.
2. Identify whether a patient may be a good candidate for
the different treatment options for the use of botulinum
toxin for myofascial pain.
3. Describe current concepts in the use of botulinum toxin
in the oral and maxillofacial areas.
Abstract
This article will demonstrate how the use of botulinum toxin
is integrated into daily dental treatment in a number of disciplines. Non-surgical, minimally invasive treatment of the
muscles of the head and neck is essential for frontline TMJ
and myofascial pain therapy as well as treatment of bruxism,
removable prosthodontics, orthodontics, periodontics, and
implant therapy.
The use of botulinum toxin, otherwise known as BoNT-A
(Botox®, Dysport®, Xeomin®), is now routinely used by dentists for treatment of their patients for both dental esthetic,
dental therapeutic, and frontline TMJ syndrome and facial
pain in the oral and maxillofacial areas. It has been estimated
that up to 25% of North American dentists now use BoNTA in their practices for dental esthetic and therapeutic uses.1
The American Academy of Facial Esthetics (AAFE) has
reported having trained nearly 7000 dental professionals
over the last 3 years in the use of BoNT-A for dental esthetic
and therapeutic uses.2 While the use of BoNT-A for esthetic
purposes has received a lot of attention in a number of dental
journal articles,3,4,5 BoNT-A pharmaceuticals are excellent
agents for dental therapeutic uses in a number of areas.
The use of BoNT-A in the oral and maxillofacial areas
is really nothing new and one can even find literature dating
back almost two decades in this arena.6 As dentists are now
accepting and treating patients with these products for soft
tissue cosmetic use to enhance the dental esthetics, BoNTA neurotoxins are getting much more attention in dentistry
than ever before. Certainly, if dentists are going to use these
therapies, training is absolutely essential and required both
ethically and by state dental boards. Research has certainly
shown that BoNT-A is a viable treatment for many facial,
TMD, and oral dysfunctions, when they are based in the
musculature.
BoNT-A products are a conservative, minimally invasive, and relatively painless therapeutic approach to dental,
facial, and head and neck areas that have frustrated many
dentists over the past 30 years. The safety of these products
is well known because of their temporary nature and they are
totally reversible over time with generally no lasting effects.
Another advantage is that it gives the patient and the dental
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05. 2013 | www.DENTALECONOMICS.com
practitioner the option to stop a therapy at any time and
return to the previous state with no ill effects.
How BoNT-A works
Acetylcholine, as you well may remember, depolarizes
the motor end plate of the muscle and will cause a muscle
contraction. BoNT-A works by inhibiting the release of
acetylcholine at the neuromuscular junction. By inhibiting
the release of acetylcholine, BoNT-A effectively will either
reduce the intensity of the contraction of the muscle or will
eliminate the contraction altogether, depending on the dosage used. Essentially, BoNT-A neurotoxin interrupts the
contraction process of the muscles and causes a temporary
muscle paralysis. This can last up to three months as the
muscle initiates new acetylcholine receptors and the growth
of branches from the neurons to form new synaptic contacts.
Gradually the muscle returns to its full function and with no
side effects whatsoever.7
When one learns how to use BoNT-A neurotoxin
properly, it can be used for a number of dental therapeutic
procedures. It can relieve TMJ syndrome and facial pain
and can retrain muscles which can certainly enhance dental
treatment plans as well as help certain facial pain disorders
that have been frustrating to the dental practitioner for many
years.
Temporomandibular joint disorder (TMD)
It almost seems as if temporomandibular joint disorder is
some kind of fad in dentistry that has gone in and out of
style. We have been told that 80% of patients have some sort
of TMD and need treatment, then it is something that you
just don’t hear about for awhile. Often, TMD is just a clinical label for any pain of the jaw and facial muscles, which
can be associated with headaches, earaches, cervical spine
disorders, and general facial pain.
Treatments that have been used for frontline TMD disorders over the years include doing nothing, psychological
therapy, maxillary or mandibular repositioning, orthotic
devices, neuromuscular therapy, drug treatments such as
anti-inflammatory agents, non-narcotic and narcotic pain
medications, spray and stretch, muscle relaxants, chiropractic therapy, massage, acupuncture, and even antidepressants, all with varying levels of success.
The use of BoNT-A therapy for TMD symptoms has
been in use for many years.8,9 Along with the introduction
of BoNT-A into dentistry, and greater education on trigger points and other minimally invasive treatments, dental
clinicians can now offer reversible, successful treatment for
TMD patients, providing long term relief.
Muscle trigger point therapy
Often, with TMD cases, there may be one or multiple trigger points in muscles that a patient points to. Palpating these
areas immediately sends a cascading pain along muscle or
neuronal tracks that radiate from the trigger point outward.
Many agents have been used and injected directly into these
trigger points to treat these areas, including sterile saline and
local anesthetic. The theory of trigger point injections is that
the disruption of the trigger point may be enough to bring
some relief, either short term or long term. The success of
these treatments have been limited, primarily because the
effect of sterile saline or local anesthetic lasts from a few minutes to only a few days. With BoNT-A as the pharmaceutical of choice, trigger point therapy for TMJ syndrome and
facial pain is now much more effective as well as predictable.
For trigger point injections, the use of BoNT-A pharmaceuticals has been highly effective because the effects will
last for three months and you are actually helping reduce the
intensity of the contraction of the muscle, which is usually
in spasm. As dental professionals we may have developed
tunnel vision and believe that fixing the dentition will solve
all of the other problems. There are many schools of thought
in dentistry that an orthognathic approach will work the best
with occlusal equilibrations and full mouth reconstructions,
which may relieve facial pain. This approach has frustrated
many dental clinicians and patients as they will finish the
case with the occlusal philosophy they have learned and then
the patient may still have mild to severe facial pain.The muscles themselves may be in need of relief in order to achieve
the right occlusal equilibration and end-point for our full
mouth reconstruction. In other words, let’s treat the muscle
pathology symptoms first and then build our occlusion to
the relieved muscles so that the facial pain will be eliminated.
Studies clearly show the relief of painful symptoms in facial
muscles with BoNT-A for up to 90% of patients who had not
responded to traditional treatments.10
For facial pain and TMD cases, BoNT-A neurotoxins can
be generally applied to a number of muscles of facial expression and mastication, including the masseter, temporalis,
frontalis, procerus, corrugator, orbicularis oris, orbicularis
oculi, mentalis, depressor anguli oris, trapezius, splenius
capitus, sternocleidomastoid, and pterygoid muscles.11 The
temporalis and masseter muscles are always treated bilaterally even if only one side of the face is involved.
The use of BoNT-A products in TMD therapy can give
clinicians a totally new insight into helping these patients
who have not found predictable relief in the past.
ease, either causes TMD and is the cause of headaches and
facial pain. Traditionally, intraoral appliances have been the
treatment of choice for bruxism with good success relieving
some or all of the symptoms.
BoNT-A products can be used to help patients with
bruxism. Proper training in the use of BoNT-A neurotoxins is essential. Some clinicians typically treat bruxism
and TMD patients with bilateral injections of BoNT-A
into the masseter and temporalis muscles. Using the right
amount of BoNT-A will reduce the intensity of contractions
of these muscles of mastication as well as give your patient
full competence for chewing, eating properly, and speaking.
The relief afforded to patients by BoNT-A neurotoxins can
help eliminate facial pain, significantly reduce their TMD
symptoms and potentially improve periodontal treatment
outcomes by removing the bruxism element.
As an example of BoNT-A treatment for both TMJ and
bruxism, figure 1 shows a patient who has experienced facial
pain and has significant bruxism. The bruxism caused considerable restoration breakage, necessitating replacement.
You can see just be looking at this patient that her masseter
muscles are in spasm even at rest giving her a square facial
appearance. This is not skeletal but is purely a result of masseter hypertrophy. Figure 2 is a close up view of the masseter
muscle in spasm. You can see the result of BoNT-A therapy
two weeks later in figure 3 - the masseter muscles are no longer in spasm and the patient’s face is much more rounded at
the corners of the mandible. Her facial pain had disappeared
and she subsequently has had successful long term dental
treatment with BoNT-A injections repeated approximately
every 4-6 months to maintain her comfort.
Figure 1. Upon observation, bilateral masseter hypertrophy is readily
apparent on this facial pain patient.
Bruxism
Bruxism is the general term that refers to both clenching and
grinding of the teeth. There have been numerous theories
as to why this occurs and most bruxism will manifest itself
nocturnally. Certainly, there are components of psychological stress that may cause it. Regardless of the causes of
bruxism, there is no question that it leads to the destruction
of otherwise healthy dentition, exacerbates periodontal dis-
www.DENTALECONOMICS.com | 05.2013
95
Figure 2. Close up view of the muscle in spasm.
Orthodontic therapy
While the role of the facial muscles in determining placement
of the teeth is fairly well known, at times dental practitioners
may forget about the muscles once the teeth are set after orthodontic therapy has taken place. Relapse has been a continual
problemformanygeneralandorthodonticdentalpractitioners
and there are a number of theories as to why this happens. It is
readily apparent that some patients have a hyperactive mentalis muscle that may be disrupting the alignment of the teeth.
Other muscles in spasm can usually be observed as well with
proper training.
BoNT-a neurotoxins can reduce muscle contraction intensity and over time it is quite possible that muscles can be
trained to work normally.This idea could revolutionize how we
deal with orthodontic relapse as dental practitioners become
more familiar with the use of BoNT-A neurotoxins.13
Figure 4. Careful treatment planning and AAFE patient mapping for
successful therapeutic outcomes.
Figure 3. After BoNT-A treatment, the facial pain and the masseter
hypertrophy are both eliminated.
Figure 5. Live patient one on one mentoring is mandatory for proper
BoNT-A continuing education.
Masseteric Hypertrophy
Masseteric hypertrophy literally means enlargement of the
masseter muscles. Most often, this is associated with clenching and bruxism, even when it is mild to moderate.
A common treatment for masseteric hypertrophy is
BoNT-A injections into the belly of the masseter muscle.12
This will cause a slenderizing of the face in addition to reducing the intensity of contractions of the masseter muscles
and like all other BoNT-A treatments, repeated injections
are required every few months. This esthetic effect will happen automatically when BoNT-A is used for TMJ syndrome
and bruxism as described above.
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05. 2013 | www.DENTALECONOMICS.com
Removable prosthodontics
The same idea described in the previous paragraph can be
applied to those patients who have trouble getting used to
removable prosthodontics. While it is true that more and
more patients everyday are receiving implant treatment to
help stabilize dentures, there will always be patients who
cannot afford implant therapy or because of underlying
challenges such as medical history or bone resorption, are
not candidates for implant therapy. If you study the facial
muscles carefully in patients, you will often times see a hypertrophic masseter and can even feel strong lateral and medial pterygoid muscles that cause the difficulty in adjusting
to removable prosthodontics. Muscle training via BoNT-A
neurotoxins may someday provide relief as dentists become
more familiar with their use.
Trigeminal neuralgia
Trigeminal neuralgia has frustrated dental clinicians for years
and is defined as a unilateral facial pain disorder that has recurrent brief, sharp, lancinating pains that are generally limited
to the distribution of one or more divisions of the trigeminal
nerve. Trigeminal neuralgia is frequently confused with dental pain and needs to be considered more often as a possible
diagnosis when all other dental and muscle pathologies have
been eliminated as the source of dental and facial pain.
BoNT-A use is increasing for trigeminal neuralgia cases
and while the mechanism of action has not been well established, it has been a useful adjunct to treating these patients
as primary or secondary treatment.14,15 The incidence of
trigeminal neuralgia is approximately 1 in 25,000. Adding
BoNT-A to the treatment plan may result in significant
relief of this disorder.
Continuing education a must
Because BoNT-A is an injectable pharmaceutical with many
oral and maxillofacial therapeutic applications. A frontline
TMJ syndrome and facial pain course with one on one
mentored live patient training as well as the anatomy, physiology, pharmacology, adverse reactions, and potential complications is a must for every dental professional before using
BoNT-A. Too often, dentists have been fearful of treating
patients with TMJ syndrome and facial pain because of the
lack of available treatment options. With muscle and trigger
point therapy with BoNT-A and other minimally invasive
treatments, every dental professional can learn how to successfully treat TMJ syndrome and facial pain with these
frontline techniques.
References
1.Common Sense Dentistry, survey, 2012, www.
CommonSenseDentistry.com
2. American Academy of Facial Esthetics private communication,
November 2012.
3. Niamtu J III. Cosmetic oral and maxillofacial surgery: the
frame for cosmetic dentistry. Dent Today. Apr 2001;20:88-91.
4. Malcmacher, L. Botox Therapy for Every Dental Practice.
Dent Today. August 2009;28:101-103
5. Malcmacher, L. Dermal Filler Therapy for Every Dental
Practice. Dent Today. August 2009;28:48-50
6. Ludlow CL, Hallett M. Rhew K, et al. Therapeutic use of
botulinum toxin. N Engl J Med. 1992;326:349-350.
7. Meunier FA, Schiavo G, Molgo J. Botulinum neurotoxins:
from paralysis to recovery of functional neuromuscular
transmission. J Physiol Paris. 2002;96:105-113.
8. Borodic GE, Acquadro MA. The use of botulinum toxin for
the treatment of chronic facial pain. J Pain 3(1):21-27, 2002.
9. Naumann M, Albanese A, Heinen F, Molenaers G, Relja M.
Safety and efficacy of botulinum toxin type A following longterm use. Eur J Neurol 13 (suppl) 4:35-40, 2006.
10.Song PC, Schwartz J, Blitzer A. The emerging role of
botulinum toxin in the treatment of temporomandibular
disorders [reviews]. Oral Dis 13(3):253-60, 2007.
11.Kurtoglu C, Gur OH, Kurkcu M, Sertdemir Y, Guler-Uysal
F, Uysal H. Effect of botulinum toxin A in myofascial pain
patients with or without functional disc displacement. J Oral
Maxillofac Surg 66(8):1644-1651, 2008.
12.Kim HJ, Yum KW, Lee SS, Heo MS, Seo K. Effects of
botulinum toxin Type A on bilateral masseteric hypertrophy
evaluated with computed tomografic measurement.
Dematologic Surgery 2003;29(5):484-489.
13.Bhogal PS, Hutton A, Monaghan A. Review of the current
uses of Botox for dentally-related procedures. Dental Update
April 2006;33(3):165-168.
14. Piovesan EJ, Teive HG, et al. An open study of botulinum-A
toxin treatment of trigeminal neuralgia. Neurology
2005;65:1306-1308
15.Allam N, Brasil-Neto JP, Brown G, Tomaz C. Injections of
botulinum toxin type A produce pain alleviation in intractable
trigeminal neuralgia. Clin J Pain 2005; 21:182-184.
Author Profile
Louis Malcmacher DDS MAGD is a
practicing general dentist and an internationally known lecturer and author known
for his comprehensive and entertaining
style. Dr. Malcmacher is president of the
American Academy of Facial Esthetics
www.FacialEsthetics.org . You can contact
him at 800 952-0521 or email [email protected]
His website is www.CommonSenseDentistry.com where
you can find information about his hottest topics schedule,
live patient Frontline Myofascial Pain training, Botox and
dermal fillers training, download his resource list, and sign
up for a free monthly e-newsletter.
Author Disclosure
Dr. Malcmacher is president of the American Academy of
Facial Esthetics.
Reader Feedback
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Questions
1. Botulinum toxin (Botox) can be used for:
a. Therapeutic uses only
b. Cosmetic and therapeutic uses
c. Cosmetic uses only
d. Has no use in dentistry at all
2. Botulinum toxin best treats:
a. Dynamic wrinkles and pain associated with
muscles in motion
b. Static wrinkles
c. Deep dermal scars
d. Acne and herpetic lesions
3. Botulinum toxin can be used for:
a. Orthodontic cases
b. Removable prosthodontics
c. Hearing loss
d. A & B
4. TMD pain can be related to:
a. Ear infections
b. Masticatory or facial muscles in spasm
c. Anatomic anomalies in the joint
d. All of the above
5. Botulinum toxin’s effectiveness is because:
a. It is a topical cream that smoothes the skin
b. It is injected under the skin to add volume
c. The toxin paralyzes the skin so it doesn’t
move
d. The toxin blocks the neurotransmission to
the motor muscles which prevents the muscle
from moving and allows the skin to smooth
out
6. Botulinum toxin can be used as a treatment
of:
a. Dental caries
b. Periodontal disease
c. TMJ and bruxism
d. All of the above
7. The use of botulinum toxin therapy for TMJ
pain symptoms
a. has been in use for many years
b. has never been used
c. should never be used
d. has only been in use for 1 year
8. Treating patients for bruxism and muscle
related TMJ pain includes injections of
which muscles:
a. Temporalis and triceps
b. Medial pterygoid and sphincter muscles
c. Biceps and temporalis
d. Masseter and temporalis
9. When pressed, a trigger point:
a. Will do nothing
b. Will send a cascading pain along muscle or
neuronal tracks that radiate outward.
c. Will send a tingling sensation without pain to
adjacent muscles
d. Will send a ticklish sensation down the arm
10. Acetylcholine depolarizes the motor end
plate of the muscle and will cause:
a. Muscle extension
b. Muscle contraction
c. The muscle to go to a neutral position
d. Nothing to happen
Notes
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05. 2013 | www.DENTALECONOMICS.com
11. Types of frontline TMJ/Orofacial pain
treatments include:
a. Therapeutic exercises
b. Bruxism splints
c. Spray and stretch
d. All of the above
12. When injecting the masseter muscles for
TMJ and facial pain:
a. These muscles are always treated unilaterally
b. These muscles are always treated bilaterally
c. These muscles are never treated for TMJ and
facial pain
d. These muscles are always treated for TMJ and
facial pain
13. When injecting the temporalis muscles for
TMJ and facial pain:
a. These muscles are always treated unilaterally
b. These muscles are always treated bilaterally
c. These muscles are never treated for TMJ and
facial pain
d. These muscles are always treated for TMJ and
facial pain
14. Often, temperomandibular disorders
(TMD) is often a clinical label:
a. For any pain in the body
b. For any dental pain
c. For any pain of the jaw and facial muscles
d. For any pain of the ear canal
15. TMD and myofascial pain cases:
a. May have only one trigger point
b. May have multiple trigger points
c. May have no trigger points
d. All of the above
ANSWER SHEET
Botulinum Toxin for Frontline TMJ Syndrome and Dental Therapeutic Treatment
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If not taking online, mail completed answer sheet to
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1. Listthemostimportantandpotentiallyusefulconceptsintheuseofbotulinumtoxininthetreatmentof
TMJ and myofascial pain
A Division of PennWell Corp.
2. Identifywhetherapatientmaybeagoodcandidateforthedifferenttreatmentoptionsfortheuseofbotulinumtoxin
for myofascial pain
3. Describecurrentconceptsintheuseofbotulinumtoxinintheoralandmaxillofacialareas
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The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General
Dentistry. The formal continuing dental education programs of this program provider are accepted by the
AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance
by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from
(11/1/2011) to (10/31/2015) Provider ID# 320452.
Customer Service 216.398.7822
RECORD KEEPING
PennWell maintains records of your successful completion of any exam for a minimum of six years. Please
contact our offices for a copy of your continuing education credits report. This report, which will list all
credits earned to date, will be generated and mailed to you within five business days of receipt.
Completing a single continuing education course does not provide enough information to give the
participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of
many educational courses and clinical experience that allows the participant to develop skills and expertise.
CANCELLATION/REFUND POLICY
Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.
IMAGE AUTHENTICITY
The images provided and included in this course have not been altered.
© 2013 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell
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