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Calis (2019)
Calis (2019)
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Original Article
A R T I C L E I N F O A B S T R A C T
Article history: Introduction: Botulinum toxin has been used mainly in the treatment of muscular temporomandibular
Received 25 November 2018 joint disorders (TMD) and hyperactivity of the masticatory muscles. It is used also as a therapeutic option
Accepted 4 February 2019 to relieve pain and help in functional recovery from dental, oral and maxillofacial surgery. The aim of our
Available online 23 February 2019
study was to investigate the efficacy of botulinum toxin injection in the treatment of muscular TMD.
Materials and methods: Of the 200 temporomandibular joint patients who applied for treatment,
Keywords: 25 patients with muscular dysfunction of the origin were included in the study. This patient group
botulinum toxin
received drug, drug - physical therapy, occlusal splint therapy and botulinum toxin. These treatments
temporomandibular joint
temporomandibular joint disorders
were performed step by step. Botulinum toxin was applied, in accordance with reflex measurement in
bruxiszm electromyography guidelines to nine patients whose results were not success from the other treatments
pain had not been successful. Measurements were taken of bite force, pain and mouth openness.
Results: Sixteen patients were treated with drug-physical therapy-occlusal splint therapy, and
botulinum toxin treatment was found to be successful in the case of nine patients. No side effects
were observed at six months follow-up.
Conclusion: Botulinum toxin injection for the treatment of muscular temporomandibular joint disorder is
a viable treatment option in the case of patients who do not respond to conservative treatment methods.
C 2019 Elsevier Masson SAS. All rights reserved.
https://doi.org/10.1016/j.jormas.2019.02.015
2468-7855/ C 2019 Elsevier Masson SAS. All rights reserved.
A. Sipahi Calis et al. / J Stomatol Oral Maxillofac Surg 120 (2019) 322–325 323
It hinders activation of calcium channels in the nerve endings [1– no systemic disease;
3,6,8–10]. BTX is also used for the treatment of focal dystonia, no edentolous jaw.
strabismus, hemifacial spasm, dystonic tics, urinary sphincter
dissynergy, cerebral palsy, myofascial pain, headache, temporo-
mandibular joint disorders and reduction of hyperkinetic facial
3. Medication
lines [2,3,5,7–9,11].
The duration of action of BTX is long and it requires two to four
Analgesic-anti-inflammatory (Lornoxicam, Xefo1 8 mg film
months for the regenerative processes to take effect. The initial
coated tablet, Abdi Abraham).
onset of the effect occurs two to three days after injection. The
Muscle relaxants (Tizanidine HCl; Sirdalud (R) 2 mg tablet,
therapeutic effect of BTX should be checked after two to three
Novartis).
weeks. Botulinum toxin gives rise to paresis when applied to
Antidepressant (Amitriptyline HCl; Laroxyl1 10 mg drage,
muscle tissue. The paresis level can be controlled by the amount of
Roche).
BTX administered. The effect of BTX is limited to the target muscle
In the first fifteen days, triple drug administration was
but three months is required for regenerate innervation. Side
performed.
effects of botulinum toxin are inevitable. These can be readily-
apparent side effects (e.g. flu-like symptoms) or not always
apparent (facultative). Local side effects (BTX-A may be diffused to 4. Medicine + Physical Therapy
neighboring tissues from the target tissue) and systemic side
effects (BTX-A can be accidentally injected into the bloodstream) Diathermy was applied to the troubled muscle area. In physical
are all categorized as facultative [12–15]. therapy, Radarmed 650 Enraf Nonius B.V. was used. Microwave
Organ damage is unlikely to occur. The targeting of muscle does warming was performed 10 times at 30 8C for 15 minutes in the
not cause necrotic or fibrotic changes. At very high doses, there affected temporomandibular joint region. Physical therapy with
may be widespread weakness, fatigue, shortness of breath, medication was carried out over the following 15 days.
dysphagia, perspiration episodes and difficulty with accommoda- An occlusal splint was used in combination with the drug
tion. therapy, beginning at the end of the first month until the third
To improve clinical success in the practice use of BTX-A in month. The occlusal splint was made in the upper jaw to raise the
temporomandibular joint diseases, these conditions need to be occlusion to 2 mm thickness for a period of six months. Pre-
met: administration blood counts were performed on all patients.
A total of 16 patients from the 25 were healed by medication,
the painful chewing muscles need to be correctly identified; physical therapy and occlusal splint. These treatments were
there should be no evidence of general hyperactivity in the applied step by step, in ascending order until one proved
masticatory muscles; successful. Nine patients (4 males, 5 females) who did not respond
the possibility of arthrogenic causes must be eliminated; to these treatments were selected to have BTX administered after
the patient must show resistance to conservative treatments for three months. Measurements were taken before and three weeks
a period of at least 3 months; after application (when the drug is at its most effective) for: bite
there must be no contra-indications to BTX-A treatment. force (using a specially- designed force meter), pain (according to
the VAS scale), and mouth openness (millimetric calculation) for
BTX is effective in relieving pain in cases of bruxism by reducing the patients who were to be administered with Botulinum toxin
local inflammation modulators. This leads to a resting position in type A. Administration of the drug was carried out in line with
the muscles by reducing the contraction force in the resulting reflex measurement in electromyography guidelines [2,5,9]. A total
muscle fibers’ contraction of inhibition. In bruxism treatment, BTX of 100 units of BTX type A were used on both sides of the face,
is recommended for temporal, masseter and lateral pterygoid including the masseter muscle for 30 units and the temporal
muscles. Doses recommended for these are 10–25 units for muscle for 20 units [7,10]. Xerostomia, jaw weakness, difficulty
temporal muscle, 25–50 units for masseter muscle and 7.5–10 chewing and cosmetic side effects were checked.
units for lateral pterygoid muscle [12,13,16]. Post-treatment follow-up was carried out for a period of six
The aim of our study was to investigate the efficacy of BTX in the months. The Chi-square test was used for statistical analysis.
treatment of muscular temporomandibular joint disorders.
5. Results
2. Material and method
The biggest of the treatment groups (38%) (16 of the 25 patients)
Between September 2003 and March 2006, 200 patients with was the drug-physical therapy-occlusal splint group (P < 0.05).
temporomandibular joint disorders were admitted to the Depart- Sixteen (64%) of the 25 patients with myogenic temporoman-
ment of Oral Surgery, Faculty of Dentistry. Twenty-five patients dibular joint dysfunction received drug-physical therapy-occlusal
who were diagnosed as having muscular temporomandibular splint. Drug-physiotherapy-occlusal splint-botox therapy was
disorders, in accordance with the Research Diagnostic Criteria for successfully applied in the case of nine patients (36%)
Temporomandibular Disorders [17], were included in the study. (P < 0.05). When the same treatments were applied to cases of
The study was carried out in the Dentistry Faculty’s Oral Surgery temporomandibular joint disease, 64% of drug-physical therapy-
Department and the Medical Faculty Neurology Department. occlusal splint and 36% of drug- physiotherapy-occlusal splint-
Approval for the study was granted by the Medical Faculty botox treatments were found to be successful.
Research Ethics Committee. The mean age of the nine patients (4 males and 5 females) who
Inclusion criteria for the study: underwent botox treatment was 33.67 years.
Bite force decreased in 4 patients, increased in 3 patients and
unsuccessful results from drug, physical therapy and occlusal remained the same in 2 patients after treatment (P > 0.05). Pain
splint (3 months of conservative treatment resistance) [1–6,9]; assessment was carried out according to VAS guidelines and the
pregnancy test ( ); reduction in pain was significant (P < 0.05). Mouth openness was
324 A. Sipahi Calis et al. / J Stomatol Oral Maxillofac Surg 120 (2019) 322–325
reduced in two patients, increased in six patients, and there was no dystonia, whiplash-associated neck pain), suggesting a potential
change in the case of one patient (P > 0.05). role in the treatment of TMDs. The diverse group of TMDs
The effect of Botulinum toxin type A injection on bite force, relating to the orofacial musculature which have shown early
biting pain and mouth openness is shown in the following graphic evidence of response to treatmentwith botulinum toxin includes
(Fig.1). the following:
No signs were found of xerostomia jaw weakness, difficulty bruxism and clenching;
chewing and cosmetic side effects at six months’ follow-up. oromandibular dystonias;
myofascial pain (often due to parafunction);
myofascial pain with secondary TMJ involvement;
6. Discussion
trismus;
hypermobility;
Temporomandibular disorders describe a spectrum of disorders
masseter and temporalis hypertrophy;
causing pain in the temporomandibular joint and surrounding
headaches [7].
structures due to hyperfunction of the muscles of mastication
[5]. The main aim of the treatment of temporomandibular joint
In the case of temporomandibular joint disease, pain arising
dysfunction is the remission of pain in the muscles and joints and
from the articular section of the joint and from muscular structures
restoration of the physiological norm for proper muscle tension
is usually evident. Inflammation and articular pain in the joint can
and loading of the joint [2]. In treating TMJ dysfunction, the use of
have a negative effect on degree of mouth openness, masticatory
analgesics, anti-inflammatories, muscle relaxants and antidepres-
strength, bite strength and pain felt when biting. The source of
sants is strongly recommended, especially when accompanied by
chronic myofascial pain is not clear [18,20].
pain, inflammation and stress. Drug treatment alone was sufficient
In a study conducted on patients with temporomandibular
in 10.5% of our patients. We take the view that pharmacological
joints, pain experienced by the patient decreased by 90% after BTX-
treatment has a relaxing effect, especially for those patients with
A application to the masticatory muscles [21]. Freund and
psychological problems, those with an excessive habit of clenching
Schwartz found that in patients with temporomandibular joints,
their teeth and those experiencing particular pain. This can
the pain in these muscles was reduced by 50% with BTX-A. In our
therefore be a valuable initial step in the treatment process.
study, pain was also found to be reduced after BTX application, but
Supportive treatment is limited in the treatment of muscular-
this time by 100%.
originated temporomandibular joint diseases. Physical therapy
Other studies by Freund and Schwartz found that patients with
and medication are reversible and offer only short-term symptom
temporomandibular joint dysfunction experienced reduced pain
relief. Symptoms may recur. BTX-A injection into the chewing
and bite strength during the active BTX-A period following
muscles is an effective method for the treatment of muscular
injection. It was observed that the degree of mouth opening also
temporomandibular joint diseases [18,19].
increased. Three processes have been recognized in relation to
Botulinum toxin type A, administered by injection into the
BTX-A’s effectiveness. Firstly, muscle loosening: reduced muscle
masticatory muscles, has been reported to be an effective
tone is explained by the inhibition of alpha and gamma neurons.
treatment method for TMJ dysfunction in recent years. In our
Secondly, the mechanism associated with reduced inflammation in
study, a total of 100 units of Botulinum toxin type A, within the
the joint and muscle. Inflammation of the joint restricts the
recommended safety limits, was administered. No side effects
movement of the capsules and ligaments. The third process is the
were observed.
relief of pain and the increase in the degree of mouth opening.
Although originally recommended for treating focal dystonias,
These three processes act together to enhance efficiency and
botulinum toxin has also been demonstrated to provide pain relief
mouth openness [18,22].
for the head (migraine, tension headaches) and neck (cervical
In their study, Schwartz et al. reported that BTX-A reduced pain
and bite strength after intramuscular injection into the area of the
muscular TMJ dysfunction and increased mouth opening [23]. Our
results indicated that, after BTX-A administration, bite strength
decreased in four out of nine patients, but this result was not
significant (P > 0.005) Pain assessment was carried out according
to VAS gudelines, and a total of nine patients showed a reduction in
pain. This result was statistically significant (P < 0.005). After
millimetric assessment of the degree of mouth opening, six out of
nine patients showed an increase after treatment. This change was
not statistically significant (P > 0.005) (Fig. 1).
This result can be attributed to the low number of patients
undergoing BTX-A. Evaluation of a large sample of patients would
make the results of the study more meaningful. However, the high
price of the drug, the side effects which may occur, and the fact that
it is a new treatment modality have all contributed to a limited
number of patients receiving BTX-A when other treatments have
failed. We believe that a study involving a large number of patients
is required which would help determine the potential for increased
use of this treatment in future.
We are of the opinion that it is useful to use this substance,
which is widely used in cosmetics, in the treatment of temporo-
mandibular joint diseases of muscular origin. Of the 25 patients
with muscular temporomandibular joint dysfunction, 16 (64%)
Fig. 1. Botulinum toxin type A injection effect on pain (green), bite force (blue) and responded to the treatment with medication-physiotherapy-
mouth openness (yellow). occlusal splint. Nine patients (36%) who did not respond to
A. Sipahi Calis et al. / J Stomatol Oral Maxillofac Surg 120 (2019) 322–325 325