Botox should not be your first line remedy for TMJ pain, despite some claims to the contrary. While I do have a handful of patients who are receiving regular injections of Botox and doing well, I have two primary objections: First, I consider Botox a band aid that simply reduces muscle contraction pain without necessarily discovering the cause. And second, Botox often fails to reduce muscle spasm enough to effectively address the pain.
A new patient I saw just yesterday illustrates the point. Renee W. a 40 year-old new mom with complaints of jaw pain, clicking, and pain when chewing said she had suffered years of occasional pain beginning in her teenage years. A few months ago, she stated that she had even locked closed once, although with physical therapy she had been able to open and that severe limited opening had not recurred.
She has also had recent Botox injections into the masseter muscles on both sides and this has provided some relief. And so you might logically say, let’s just do Botox every few months for the rest of her life.
While that might be appropriate, I’d like to find out why she has the symptoms. What is the cause?
Since this is a TMJ focused practice, one of our first steps is to obtain joint images. I was somewhat surprised to see that Renee had textbook perfect joint alignment with excellent disc spacing and condyles well centered in the glenoid fossae. She also had normal range of motion.
“So, you’re telling me that these problems have been going on for years. Did you have braces as a youngster?” I asked her.
“And your problems started then or shortly after?”
“Well, I guess so. I don’t remember exactly when it started, but it has been years. It’s just been getting worse lately.”
If her joints look normal, where else should we look? How about occlusion?
Here’s a computer scan of Renee closing on her back teeth, C.O. or MIP in dental talk. Plain to see things aren’t exactly perfect if perfect means every tooth touching at the same time with about the same amount of force. In fact, this looks like a big problem. The questions abound: did her orthodontist leave her like this? Likely yes, but we’ll never know. Does she have a tongue thrust habit causing that anterior open bite? It’s a place to look. It is certainly not normal to have zero front tooth contact.
Next, what happens when Renee chews and moves her lower jaw side to side? Here is a graphic of her tooth contact when she chews on the right. I think any dentist will tell you that this is a huge problem. Research conducted by Dr. Robert Kerstein shows that if there is not an almost instant disclusion of posterior teeth during lateral movement then there will be significant adverse contraction in the muscles of mastication.
Renee’s occlusal problem is worse than that because there is no disclusion at all, just extreme interference on the first molars on the right side. I suppose she’s lucky that she has not fractured the buccal cusp of #3 or lingual cusp of #30-yet.
Left lateral excursion also shows no canine guidance and in this case again she’s contacting on the right side (a non-working side interference).
What to do with a problem like Renee’s? In my opinion she should have orthodontics again. As you might imagine, that wasn’t a welcome suggestion. “What? Can’t you just make a night guard that will fix me?”
I don’t think so. How much good will a night guard do for someone who has excessive right side force every time she closes—and she closes to swallow every two minutes during her waking hours. What good will a night guard do for someone who cannot eat without pain. No, her occlusion needs to be corrected and in a major way. A little equilibration will not suffice for her.
What’s the take home lesson here? Listen to your patient and then look. Really look. Years ago, I heard Dr. Ron Jackson tell a group, “If your patient is breaking back teeth, look at the cuspids.” Meaning, if your patient is fracturing posterior teeth, maybe she doesn’t have canine guidance. Well, I’d expand that to this: If your patient has symptoms of TMJ pain, look at the cuspids and look for lateral interferences. Maybe there is real TMJ pathology, but take a careful look at occlusion. There may not be any simple answers, but Look.
So, should she just do Botox every few months for the next few decades? That’s the approach that some are following. But why not address the cause?
To the dentist: would you be interested in a hands-on workshop on the use of T-scan to carefully analyze your patients’ occlusion, the results of your restorative dentistry, help with equilibration and so on? Other possible topics could include interpretation of CT scans and MRI, orthotic fabrication for TMD and more. Feel free to contact me.