Introduction
TMJ, or Temporomandibular Joint Syndrome, is a condition characterized by jaw tension and pain. Typically caused by either teeth grinding or jaw clenching, this condition can cause headaches and lockjaw. TMJ is often confused with an earache because of the location of the joint, and severe cases can inhibit talking, chewing and swallowing. Botox injections are used off-label to treat TMJ and have shown promising results.
Q & A
Benefits of Dentox (Botox for Dentistry)
The most common benefit of Dentox (Botox for Dentistry) is the reduction in the number of clenching events and their intensity. This will reduce the destruction of your teeth, gums and jaw joint, and reduce the discomfort and pain in your face, jaw joint, teeth and chewing muscles. Other benefits include the elimination of tension headaches and migraines. Botox may also be used to relax muscles that prevent mouth opening. The upper lips can be relaxed to prevent the gums from showing too much when smiling. Excessive and uncontrolled salivary flow can be reduced. A beneficial side-effect may be the smoothing of lines between the brows and in the forehead when treated in this area. The results are often seen within 24 – 48 hours.
Is Botox safe?
Yes. Botox is a natural protein. It is the most powerful muscle relaxant with the least side-effects. Another safety benefit is that the botulinum toxin does not stay in the body indefinitely, so if there is an adverse effect, or a mistake made, it is only temporary. There is also the likely possibility that with frequent treatments, the injected muscles will atrophy allowing the patient to go longer and longer between treatments. It affects only the area treated and has no effect at all on the rest of the body.
What can I expect at the initial consultation?
At the initial consultation your doctor will first determine if you are an appropriate candidate (see ideal candidate) for Botox and if indeed it is the best treatment for the results you desire. You should also discuss your medical history with your doctor. He/she will assess if you are allergic or hypersensitive to any ingredient in Botox. Furthermore, it is imperative that you disclose all medications, vitamins, herbs, and supplements you currently take. These substances could hinder or intensify the potency of the Dentox (Botox for Dentistry) or cause bleeding and bruising at the injection sites.
Botox Injection - The Procedure
Botox is a simple, non-surgical procedure. The doctor will have you contract the muscle area to be treated so he/she can determine appropriate injection sites. He may use an electronic muscle locating device (EMG) to exactly locate the targeted muscle site. Then targeted injected areas may be numbed with an ice pack or a topical numbing agent. Anesthesia may or may not be used. Finally, the doctor will administer several tiny injections of Botox directly into the muscle or gland. Only the injected areas will be "Botoxed" It will not affect anywhere else in your body.
How long is the procedure?
The length of the procedure depends on the number of injections needed as determined by the doctor. Still, it is reasonable for the procedure to be completed within 10-30 minutes.
What, if any, hospital stay is required?
Because the procedure is non-surgical and often done right in the doctor’s office, there is no hospital stay required.
Will I need a driver?
No.Botox will not limit your driving ability
How much pain is there?
The pain associated with this procedure is due to the injections, but it is generally minimal and brief. Some patients have likened it unto a "bug bite" or "prick". Pain can be reduced by proper injection techniques and by numbing proposed injection sites with a cold pack or anesthetic cream. If you are scared of needles the doctor may offer you Happy Gas or even a sleeping pill.
What can I expect afterwards?
Muscle tenderness will start to disappear almost immediately. Pain and wrinkles begin to disappear within 24 – 48 hours after the injections, and the patient may continue to see the wrinkles diminish up to one week after the procedure. Salivary flow may be reduced after 3-4 days (only when treated specifically for this). There may be mild temporary bruising, numbness, or redness around the injection sites. A small number of patients reported no noticeable difference in the reduction of their wrinkles.
How does it effect salivary flow?
Salivary flow usually is reduced when injected directly into the salivary glands. You will notice a reduction in 4 to 7 days. The maximum effect will occur in 3 weeks after your treatment. The effects will diminish after 3 to 4 months.
What is the recovery like?
Because the procedure is non-surgical and non-invasive, it is highly likely that the patient can return to normal activities immediately. However, to avoid spreading the toxin to other muscles, patients should not rub or massage the area injected and remain upright for many hours. Physical activity should also be limited for a time.
What is the long-term outcome?
Results of Botox generally last up to four months. Patients should wait at least three months between treatments. There is also the likely possibility that with repeated treatments, the injected muscles will atrophy allowing the patient to go longer and longer between sessions. Do not have Botox treatments more often than every 3-4 months or elsewhere because they may weaken the affects of Botox in your body.
With more and more injections, there is a chance of growing resistant to Botox. Your body may develop antibodies that would cause treatments to become less effective over time. This resistance can be minimized by using the lowest dose possible and extending the intervals between sessions. It is best to limit your Botox injections to one office. Your dentist may be able to take care of all your Botox needs.
How long do the results last?
The problem treated will disappear for up to four months. The smooth, diminished appearance of the wrinkles will last up to four months. Results may last longer with subsequent treatments due to muscle atrophy. If another round of Botox is not performed, facial or chewing muscle discomfort may return. Excessive salivary flow may recur.
Who is an ideal candidate?
Botox may or may not be the best treatment for the results you desire. An ideal candidate meets the following conditions:
• Between the ages of 18-65
• Has a dento-facial problem caused by parafunctional muscle activity
• Has a drooling problem
• Does not object to the disappearance of his/her wrinkles
• Is looking for a non-surgical solution
• Is looking for a temporary solution
• Is knowledgeable about the procedure
• Is realistic in expectations
• Is in good physical and psychological health
• Is not pregnant or nursing
The above criteria are not comprehensive. Be sure to discuss with your doctor if you are an ideal candidate for Botox and if it is the best treatment plan for your desired results.
Other important information:
With the FDA’s approval of Botox, it has become increasingly popular to administer it in social settings and/or non-medical facilities, sometimes without trained personnel. Although, this can help reduce the costs for patients, they should be aware of some of the concerns. First of all, it is imperative to have a qualified, trained doctor or dentist administer the injections (see choosing a doctor). Next, the environment needs to be sterile and equipped to handle any adverse effects. A physician’s office or clinical setting is best. Finally, adherence to post-treatment instructions is key, and these may be neglected in a social/party-like atmosphere. It goes without saying that alcohol should not be a part of any medical procedure.
Some other restrictions are that Botox injections cannot be performed if there is any infection at the injection sites, if you are hypersensitive to any ingredient in the botulinum toxin type A, or if you are pregnant or nursing. There is an increased risk with patients that have any neuromuscular disorders.
Risks, Limitations & Possible Complications
As with any medical procedure there are possible risks and side effects. Since this is a non-surgical procedure, the risks and possible complications are infrequent, minimal and temporary. The most common reported side-effects are headaches, respiratory infection, flu syndrome, temporary eye-lid droop, and nausea. Less commonly reported effects are pain, redness at spot of injection, and muscle weakness. These symptoms are thought to connected with the injection and occur within the first week. There could also be bruising at the injection site. The lips are used more than the forehead for common activities such as chewing, kissing, and talking. Therefore injections around the mouth are less useful and can have more potential inconvenient effects. These every day activities may become more difficult and too much Botox around the mouth can result in drooling. Another limitation to Botox injections is that there is a possibility of developing antibodies that would render the treatments less and less effective over time. This resistance could be delayed by using the lowest effective dose possible over the longest intervals of time. Botox injections should be avoided during pregnancy and lactation .
Botox Costs:
Depending on the number of injections and the doctor, treatment can cost anywhere from $500 to $1500.
Choosing a Dentist or Doctor
Any health care professional can administer Botox injections. However, a dentist, facial plastic surgeon, neurologist, or dermatologist is recommended. He/she should be experienced in botulinum toxin injections and have an intricate understanding of facial anatomy and physiology.
Questions to ask your doctor
• What are your credentials? Have you been trained in the use of Botox?
• Have you ever had your malpractice insurance denied, revoked, or suspended?
• Are Botox injections the best treatment plan for my dental condition or should I consider alternative treatments?
• How many Botox treatments have you performed?
• What percentage of patients have had significant complications? (The dentist should disclose this information to you.)
• Could I observe this procedure before I have it done? (Either on videotape or in real life)
• Where will the treatment be performed?
• How long will it take?
• How should I prepare my mouth or skin for treatment?
• Will you repeat or correct procedures if it does not meet agreed upon goals?
• If the procedure is repeated/corrected, will I be charged again? (The dentist should provide you with his/her policy on this issue.)
• What are the risks or complications?
• What are the post-treatment instructions?
• If I am interested in maintaining the results, when will I need to return for another round of Botox? How soon can I return?
• What is the cost per injection?
• Do you offer patient financing?
The treatment of patients in the dental office with disabling primary jaw pain and headache remains a challenge for clinicians.
Acute therapy to rapidly alleviate suffering is provided by drugs of several classes, including
analgesics, opioids, serotonin agonists, dopamine antagonists, and prostaglandin inhibitors.
While providing varying levels of short-term relief, these drugs do not prevent future attacks, may be overused by patients having frequent headaches, and pose the danger of adverse events and drug interactions. Long-lasting prevention is a preferable approach for patients with disabling, chronic headache.
Candidates for Preventive Treatment
The key to accurate diagnosis is a comprehensive pain history. Pain is a
subjective experience, and some patients cannot clearly describe what they are feeling.A
precise and helpful history, though it may take time to elicit, is indispensable to diagnosis.
Although diagnostic tests can establish or exclude secondary disorders, there are no precise
diagnostic tests for many pain syndromes, including migraine and cluster headaches.
Many patients with migraine or tension-type headache require careful management and,
frequently, derive significant benefit from preventive therapy. After a thorough history is
obtained and headaches from other causes (eg, tumor, infection, systemic illness) are ruled out by examination, patients with primary headache who meet one of the following criteria may be considered likely candidates for preventive treatment:
Candidates for preventive therapy:
• Qualified candidates for preventive treatment based on US Headache Consortium Guidelines (see Appendix A)
• Patients with chronic daily headache
Candidates for botulinum toxin type A injections:
• Headache refractory to routine preventive treatment
• Patient preference
• Cranial cervical dystonia
• Noncompliance with oral medications
• Contraindications, noncompliance, or adverse events from standard prevention
• Coexisting jaw, head, or neck muscle spasm
Treatment Plans
The patient treatment plan should be based on:
_ Diagnosis
_ Specific symptoms
_ Comorbid conditions
_ Patient expectations
_ Patient needs
_ Patient goals
Patients should be informed of the:
_ Goals of treatment
_ Purpose of each component of the treatment plan
_ Need for follow-up care
_ Potential adverse events
In the prevention of headache, the primary goal is to improve the patient’s quality of life. Results of preventive treatment that indicate success include:
_ Decreased frequency and intensity of headache
_ Improved function and decreased disability
_ Reduced use of other headache medications
_ Increased efficacy of acute headache medications
Drugs Used for Headache Prevention
While nonpharmacologic measures such as splints, diet and exercise can help to reduce the likelihood of frequent headaches,many drugs are currently used for the prevention of disabling primaryheadache. They do not work consistently for all patients, however, and most are not approvedby the FDA for treatment or prevention of headache. Drugs commonly prescribed to preventmigraine include (for specific drugs in each class, refer to Appendix A for Internet access to theUS Headache Consortium Guidelines):
_ Anticonvulsants
_ Antidepressants
_ Beta-blockers
_ Calcium channel antagonists
_ Conventional NSAIDs and selective COX-2 NSAIDs
_ Serotonin antagonists
Some of these medications can be particularly useful when the migraine patient has a
comorbidity for which the drug is indicated (eg, hypertension or angina for beta-blockers and
calcium channel antagonists; depression for antidepressants). However, these medications also
may cause significant adverse events (see below).
Except when the frequency of tension-type headache exceeds 15 days with headache/
month, prophylactic medication is not required. Antidepressants, particularly tricyclics, and
NSAIDs are frequently prescribed for prevention of tension-type headache, as are muscle
relaxants. While muscle relaxants may seem a logical choice for tension-type headache
associated with disorders of the pericranial muscles, there is a lack of clinical trial data to
support their use as monotherapy for prevention. Patients who receive prophylactic medication
still require acute treatment for breakthrough attacks, and many patients report that their acute attacks are more manageable while they are receiving preventive medication.
Adverse Events of Preventive Therapies
The adverse events experienced by patients taking drugs of these classes are well defined and
often prove intolerable to patients being treated prophylactically for headache.
Beta-blockers may cause:
– Fatigue
– Dizziness
– Sexual dysfunction
Tricyclic antidepressants are associated with:
– Dry mouth
– Drowsiness
– Weight gain
– Constipation
Selective serotonin reuptake inhibitors may cause:
– Insomnia
– Sexual dysfunction
Patients taking calcium channel antagonists may experience:
– Constipation
– Edema
The potential for gastrointestinal or renal adverse events of chronic NSAID use is well documented, and muscle relaxants can lead to:
– Sedation
– Dizziness
The adverse-event profile of anticonvulsants includes:
– Weight gain/loss
– Hair loss
– Nausea
– Tremor
– Cognitive dysfunction
– Drowsiness
– Dizziness
– Fatigue
In prescribing these drugs for headache prophylaxis, titration to maximize efficacy and minimize adverse events is recommended. Migraine patients often require a lower dose of a preventive
medication than is needed for other, approved indications of the drug. Headache patients may
also be more sensitive to a medication’s adverse events. An adequate trial (2 to 6 months) of
each prophylactic treatment should be made before concluding that the agent is ineffective.
Oral contraceptives, hormone replacement therapy, and vasodilators may interfere with the
efficacy of some preventive drugs, and migraine patients should not overuse analgesics,
opioids, triptans, or ergot derivatives during a trial of prophylactic treatment.
Choice of preventive treatment depends on the drug’s efficacy and adverse-event profile,
and on the patient’s clinical features, frequency of headache, response to prior treatment, and possible comorbidities. Current preventive treatments, unfortunately, are less than adequate for the majority of patients and,when they do work, their efficacy lessens over time. Drug-drug interactions are also a source of concern. The shortcomings of current preventive strategies for headache patients make results of recent clinical trials of botulinum toxin for headache treatment particularly compelling.
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