Earn1 CE creditThis course was

written for dentists, dental hygienists,

and assistants.

AbstractThis 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, periodon-tics, 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 ProfileLouis 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 drlouis@FacialEsthetics.com His website is www.Com-monSenseDentistry.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 DisclosureDr. Malcmacher is president of the American Academy of Facial Esthetics.

Publication date: May 2013 Expiration date: Apr. 2016 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 hhodges@pennwell.comEducational 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.

Supplement to PennWell Publications

PennWell designates this activity for 1 Continuing Educational Credit

Dental Board of California: Provider 4527, course registration number CA#: 01-4527-13021“This course meets the Dental Board of California’s requirements for 1 unit of continuing education.”

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.

Go Green, Go Online to take your course

Botulinum Toxin for Frontline TMJ Syndrome and Dental Therapeutic TreatmentA Peer-Reviewed Publication Written by Louis Malcmacher DDS MAGD

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Educational ObjectivesAt 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.

AbstractThis article will demonstrate how the use of botulinum toxin is integrated into daily dental treatment in a number of dis-ciplines. 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 den-tists 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 BoNT-A 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, BoNT-A 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 inva-sive, 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

practitioner the option to stop a therapy at any time and return to the previous state with no ill effects.

How BoNT-A worksAcetylcholine, 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 dos-age 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 clini-cal 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 dis-orders 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, chiroprac-tic therapy, massage, acupuncture, and even antidepres-sants, 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 trig-ger points and other minimally invasive treatments, dental clinicians can now offer reversible, successful treatment for TMD patients, providing long term relief.

Muscle trigger point therapyOften, with TMD cases, there may be one or multiple trig-ger points in muscles that a patient points to. Palpating these

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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 min-utes to only a few days. With BoNT-A as the pharmaceuti-cal 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 pharma-ceuticals 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 mus-cles 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 expres-sion 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 bilater-ally 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.

BruxismBruxism 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 psycho-logical 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-

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 neuro-toxins 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 con-siderable 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 mas-seter 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 lon-ger 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.

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Masseteric HypertrophyMasseteric hypertrophy literally means enlargement of the masseter muscles. Most often, this is associated with clench-ing 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 re-ducing 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 hap-pen automatically when BoNT-A is used for TMJ syndrome and bruxism as described above.

Orthodontic therapyWhile 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 orth-odontic therapy has taken place. Relapse has been a continual problem for many general and orthodontic dental practitioners and there are a number of theories as to why this happens. It is readily apparent that some patients have a hyperactive men-talis 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 in-tensity 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 2. Close up view of the muscle in spasm.

Figure 3. After BoNT-A treatment, the facial pain and the masseter hypertrophy are both eliminated.

Figure 4. Careful treatment planning and AAFE patient mapping for successful therapeutic outcomes.

Figure 5. Live patient one on one mentoring is mandatory for proper BoNT-A continuing education.

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Removable prosthodonticsThe 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 hy-pertrophic masseter and can even feel strong lateral and me-dial 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 neuralgiaTrigeminal neuralgia has frustrated dental clinicians for years and is defined as a unilateral facial pain disorder that has recur-rent 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 den-tal 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 estab-lished, 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 mustBecause 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, physi-ology, pharmacology, adverse reactions, and potential com-plications 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 suc-cessfully treat TMJ syndrome and facial pain with these frontline techniques.

References1. 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 long-term 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 ProfileLouis Malcmacher DDS MAGD is a practicing general dentist and an interna-tionally 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 drlouis@FacialEsthetics.com 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 DisclosureDr. Malcmacher is president of the American Academy of Facial Esthetics.

Reader FeedbackWe encourage your comments on this or any PennWell course. For your convenience, an online feedback form is available at www.ineedce.com.

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Online CompletionUse this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.

Questions

1. Botulinum toxin (Botox) can be used for:a. Therapeutic uses onlyb. Cosmetic and therapeutic usesc. Cosmetic uses onlyd. Has no use in dentistry at all

2. Botulinum toxin best treats:a. Dynamic wrinkles and pain associated with

muscles in motionb. Static wrinkles c. Deep dermal scarsd. Acne and herpetic lesions

3. Botulinum toxin can be used for:a. Orthodontic casesb. Removable prosthodonticsc. Hearing lossd. A & B

4. TMD pain can be related to:a. Ear infectionsb. Masticatory or facial muscles in spasmc. Anatomic anomalies in the jointd. All of the above

5. Botulinum toxin’s effectiveness is because:a. It is a topical cream that smoothes the skinb. It is injected under the skin to add volumec. The toxin paralyzes the skin so it doesn’t

moved. 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 cariesb. Periodontal diseasec. TMJ and bruxismd. All of the above

7. The use of botulinum toxin therapy for TMJ pain symptoms a. has been in use for many yearsb. has never been usedc. should never be usedd. 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 tricepsb. Medial pterygoid and sphincter musclesc. Biceps and temporalisd. Masseter and temporalis

9. When pressed, a trigger point:a. Will do nothingb. Will send a cascading pain along muscle or

neuronal tracks that radiate outward.c. Will send a tingling sensation without pain to

adjacent musclesd. Will send a ticklish sensation down the arm

10. Acetylcholine depolarizes the motor end plate of the muscle and will cause:a. Muscle extensionb. Muscle contractionc. The muscle to go to a neutral positiond. Nothing to happen

11. Types of frontline TMJ/Orofacial pain treatments include:a. Therapeutic exercisesb. Bruxism splintsc. Spray and stretchd. All of the above

12. When injecting the masseter muscles for TMJ and facial pain:a. These muscles are always treated unilaterallyb. These muscles are always treated bilaterallyc. These muscles are never treated for TMJ and

facial paind. 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 unilaterallyb. These muscles are always treated bilaterallyc. These muscles are never treated for TMJ and

facial paind. 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 bodyb. For any dental painc. For any pain of the jaw and facial musclesd. For any pain of the ear canal

15. TMD and myofascial pain cases:a. May have only one trigger pointb. May have multiple trigger pointsc. May have no trigger pointsd. All of the above

Notes

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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 POLICYAny participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

IMAGE AUTHENTICITYThe images provided and included in this course have not been altered.© 2013 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell

Educational Objectives1. 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

Course Evaluation1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No

Objective #2: Yes No

Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.

2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0

3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0

4. How would you rate the objectives and educational methods? 5 4 3 2 1 0

5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0

6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0

7. Was the overall administration of the course effective? 5 4 3 2 1 0

8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0

9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0

10. Do you feel that the references were adequate? Yes No

11. Would you participate in a similar program on a different topic? Yes No

12. If any of the continuing education questions were unclear or ambiguous, please list them. ___________________________________________________________________

13. Was there any subject matter you found confusing? Please describe. ___________________________________________________________________ ___________________________________________________________________

14. How long did it take you to complete this course? ___________________________________________________________________ ___________________________________________________________________

15. What additional continuing dental education topics would you like to see? ___________________________________________________________________

___________________________________________________________________

ANSWER SHEET

Botulinum Toxin for Frontline TMJ Syndrome and Dental Therapeutic TreatmentName: Title: Specialty:

Address: E-mail:

City: State: ZIP: Country:

Telephone: Home ( ) Office ( )

Lic. Renewal Date: AGD Member ID:

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 1 CE credit. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822

BOTTOX513DIG

AGD Code 181, 182