Beyond the night guard: New-age injectables for TMDs

Miranda Brooks Roldán, BSDH, RDH

Over the years, temporomandibular disorders (TMDs) have been a challenge for dentists to treat in patients who are seeking a therapeutic solution to facial pain, bruxism, and masseter hypertrophy. TMDs remain a bit of a mystery within the dental field, which has been known to have limited capacities to treat the direct cause of such pain. Due to the various reasons such disorders can develop and the location of the joint itself, it has been difficult to provide complete relief from jaw pain, yet so many people are affected. The National Institute of Dental and Craniofacial Research estimates that more than 10 million people suffer from pain in and around the ear and jaw region.¹

Treatments have included psychological therapy, maxillary or mandibular surgical repositioning, various orthotic devices, neuromuscular therapy, anti-inflammatory medications, nonnarcotic and narcotic pain medications, muscle relaxants, chiropractic therapy, massage, acupuncture, and antidepressants.² Many treat the symptoms of TMDs, but few actually address the source of the pain.

The night guard

Oftentimes, the night guard is the first line of defense and the first device dentists prescribe to patients who suffer from TMDs due to its effectiveness and convenience to fabricate. Although the night guard has proven effective for relief of clenching and protection against bruxism, it provides only a partial solution, limited to the evening hours while the patient wears the device. Daytime clenching is a challenge for people like me, whose symptoms do not just manifest nocturnally. Patient compliance is also a challenge.

What is botulinum toxin, and how can it help TMDs?

Botulinum toxin injectableshave been increasing in popularity as the perfect nonsurgical solution for common TMD symptoms. Formally considered taboo in dentistry, botulinum toxingained its fame due to its cosmetic properties, but it has since earned its reputation as a wonderful alternative to the traditional treatments of TMDs. It is estimated that up to 16% of North American dentists now use botulinum toxin products for esthetic and therapeutic purposes in their practices.²

Botulinum toxin type A (BoNT-A) is a neuromodulator. Put simply, it acts as a muscle relaxant to the areas where it is injected. BoNT-A inhibits the release of acetylcholine (an organic chemical) at the neuromuscular junction. Acetylcholine works by depolarizing the motor end plate of the muscle, thus causing a muscle contraction. When the release of acetylcholine is inhibited by BoNT-A, the muscle contraction reduces in intensity. BoNT-A can eliminate the contraction altogether, depending on the dosage. BoNT-A essentially causes temporary paralysis by interrupting the contraction process of the muscle.² To clarify, the neuromodulator only helps with pain that directly stems from the muscles that control the movement of the jaw. It does not help with pain stemming from the jaw joint itself.³

The solution specifically used for this procedure is called Xeomin, and it is FDA approved for esthetic procedures.¹ Xeominis the purest form of botulinum toxin that is available with none of the bacterial proteins that Botox possesses.4 Many patients have been known to develop antibodies against Botox, so it is rarely used anymore.³

Author’s note: The brand name “Botox” is often used colloquially to refer to botulinum toxin products—including Xeomin, although they are not the same product—since many patients are familiar with it.

My story

Ten years ago, I fell victim to the stress-induced clenching habit—ironically, when I first started hygiene school—and the chronic pain has accompanied me throughout my life here in New York City ever since. It was something I just lived with and tried to manage on my own, using various devices such as an NTI-tss (Nociceptive Trigeminal Inhibition tension suppression system), aligners, and my beloved sparkly purple night guard. In addition to using the devices, I tried to ease stress with holistic practices such as yoga and meditation, but I still hadn’t found relief during moments of high stress when the pain manifested in my overworked masseter muscle. It felt as if I was working out my jaw for eight hours a day nonstop, and I was always sore, tender to the touch, and stiff. I had all the symptoms, including occasional migraines and limited opening of my jaw with clicking and popping. I was seeking relief and empathized with my patients who were experiencing the same pain and frustration. I was determined to find a solution not only for me but for my patients as well.

When I first heard of botulinum toxin products, I was only familiar with them from a cosmetic standpoint. To me, botulinum toxin was known for vanishing wrinkles and for being the cause of many frozen faces of actresses on soap operas. Although this is true, I also had this misconception that it was only for the vain and never thought that it could be used as a therapeutic aid. As I started to do more research, I realized it’s used for more than cosmetic purposes. Botulinum toxin products can also be used in managing overproduction by sweat glands, finding relief from migraines, treating eye muscle disorders, and treating overactive bladders, just to name a few.5 The neuromodulator was first used therapeutically in the 1980s to treat eye muscle spasms and wasn’t FDA approved for esthetics until 2000.5 Although it has yet to be FDA approved for TMD treatment specifically, I was curious and determined to find some relief. After careful consideration and review of the potential side effects, I decided to get the procedure done for myself at my office.

Author’s note: I received my treatment from Mellanie Kim, DMD, at Central Park West Dentistry. Watch a video of it at bit.ly/2Ftvr3X.

What is treatment like?

Despite my nervousness about this new procedure, it was quick and virtually painless. I was impressed. In our office we schedule patients for 30-minute appointments, even though the procedure takes about five to 15 minutes. This allows time for the doctor to go over any questions, prepare the solution, mark the areas of injection, and review postoperative instructions. The dentist palpated my masseter and temporalis muscles and used a pen to mark the exact spots where she would give the injections. A total of 50 units of Xeomin was used. If you have ever tried acupuncture, I would say that is the closest form of “pain” I could relate to the procedure—a small prick lasting only a second. I barely felt the insertion of the needle and the solution. After a few hours, I even forgot that I had gotten the procedure done!

You are a candidate for botulinum toxin injectables if you experience the following:

• Soreness in jaw area
• Tenderness when masseter muscle is palpated
• Tension headaches or migraines from overactive muscles
• Daytime or nighttime clenching or grinding
• Limited opening due to tight muscles

Contraindications to treatment

• Pregnancy
• Breastfeeding
• Multiple sclerosis
• ALS
• Parkinson’s
• Breathing issues, such as severe asthma or emphysema
• Bleeding issues

Side effects

• Headaches
• Respiratory infection
• Flu symptoms
• Temporary eyelid droop
• Bruising at injection site
• Nausea
• Slimming face
• After care and results

The first few hours immediately following treatment are the most crucial for the neuromodulator to bind to the receptors of the muscle. It is very important not to touch the areas for three to four hours because you could push the solution into a different site. Heat, sun exposure, and exercising are off limits as well. Heat can prevent the neuromodulator from binding correctly, which will diminish results.3 Effects can take up to a week to be felt.4

Important things to know and tell patients prior to treatment

Although the solutions Botox and Xeomin are approved by the FDA, the procedure for therapeutic treatment of TMDs has not yet been approved, but it is in the works. This procedure was first created to slim the face for cosmetic reasons, and it was found to provide relief within the masseter muscle.6

An advantage and disadvantage of botulinum toxin products is that they are temporary. The effects of treatment last anywhere between five and six months, depending on how fast the solution is metabolized. Essentially, new acetylcholine receptors and branches start to grow, forming new synaptic contacts, and the solution is no longer effective. The muscle then gradually returns to its original full function with no side effects.2 The good news is that if you find that botulinum toxin injectables aren’t for you or your patients, the injections will wear off. The bad news is that if you do end up loving the results, they will ultimately wear off.

Jaw exercises immediately after treatment are encouraged. Chewing crunchy or chewy foods also stimulates and facilitates the effects of the solution. Patients should limit the use of blood thinners and anti-inflammatory medications as these can increase bruising at the injection site; however, they will not diminish the effects of the solution.3

The future of botulinum toxin products and your role as a therapeutic advocate

As dental hygienists, we wear many hats, but our main objective is to be advocates for oral health. Offering patients options and treatment that best fits their needs is within our scope of practice. The effects of TMDs and bruxism can contribute to periodontal disease long-term. Not only can treatments with botulinum toxin help manage pain, but they can also offer patients an alternative solution to managing their condition and aid in their overall health. Up to 90% of patients stated that they felt relief from the procedure.

As more treatment options become available and we make strides in medical advances, it is important to stay current with alternative treatment options and have open conversations with your practicing dentist(s) about their philosophies on managing TMDs. Studies have shown when BoNT-A was used for cosmetic purposes, the results actually lasted longer in patients who maintained a schedule of routine treatments.2 If this same theory applies in dentistry, we can expect to see results lasting longer in the future, offering a more long-term solution for the treatment of TMDs.

Depending on the cause of your patients’ pain, and if they are good candidates, consider botulinum toxin injectables for TMDs as an alternative therapeutic solution to night guards, medications, or surgery. If your patients are looking for relief from chronic pain, this could be a great option to integrate into your practice of dentistry.

References

1. Facial pain. National Institute of Dental and Craniofacial Research website. https://www.nidcr.nih.gov/research/data-statistics/facial-pain. Accessed June 9, 2018.
2. Malcmacher L. Botox use for dental and facial pain treatment. American Academy of Facial Esthetics website. www.facialesthetics.org/blog/botox-use-dental-facial-pain-treatment. Published July 10, 2014.
3. Kim M. Botox for TMJ. Central Park West Dentistry website. https://cpwdentistry.com/botox-for-tmj. Published April 19, 2018. Accessed June 9, 2018.
4. How it works. Xeomin website. https://www.xeominaesthetic.com/how-it-works. Accessed June 9, 2018.
5. What are the differences between Botox Cosmetic and Botox Therapeutic? Lougheed Laser Centre. http://lougheedlaser.com/differences-botox-cosmetic-botox-therapeutic. Published October 9, 2017.
6. Botox treatments for TMJ. American Academy of Facial Esthetics website. https://www.facialesthetics.org/tmj-treatments. Accessed June 9, 2018.