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Type A botulinum toxin in the treatment of chronic facial pain associated with masticatory hyperactivity
Abstract
Chronic hyperactivity of the masticatory muscles is a common functional disorder associated with chronic facial pain and headache. The positive therapeutic effect of botulinum toxin type A on functional disorders and pain symptoms has been known in connection with the treatment of cervical dystonia. The purpose of this report is to assess whether the targeted reduction of masticatory muscular hyperactivity by local injection treatment with botulinum toxin type A can improve facial pain headache symptoms in the event that other treatment methods prove ineffective. Materials and Methods: In an randomized blinded placebo-controlled study, 90 patients (60 verum and 30 placebo) with chronic facial pain were treated with botulinum toxin type A (Botox; Allergan, Ettlingen, Germany) injections into masticatory muscles.
Ninety-one percent of patients who received botulinum toxin improved by a significant mean reduction of approximately 3.2 on a visual analog pain scale. By comparison with t test and chi(2) test, there was a significant difference compared with the placebo group (P <.01).
The local injection of botulinum toxin type A constitutes an innovative and adequately efficient treatment method for chronic facial pain associated with hyperactivity of the masticatory muscles. An improvement in the painful symptoms can be expected in up to 90% of patients who do not respond to conservative treatment methods.
... Other pain-related illnesses, such as fibromyalgia, immunological disorders, sleep apnea, and psychiatric illness are also regularly linked to TMDs (e.g., chronic headaches) [21,[25][26][27]. As a result, the degree of discomfort and dysfunction, as well as the course of symptoms, determines the necessity for treatment [28][29][30][31]. ...
... Clinically differentiating serious abnormalities that require treatment from incidental findings in individuals with facial pain from other sources is crucial for the clinician treating patients with TMDs [28]. Nonpharmacologic therapy, conservative pharmacotherapy, and open surgery are all forms of treatment for TMDs [32,33]. ...
... Guarda-Nardini et al. [27], comparing single-session BoNT injections or multiple-session fascial manipulation, showed that, although fascial massage was slightly superior to minimize subjective pain perception and BoNT injection was slightly superior to increase jaw range of motion, the two therapies appear to be almost equally effective. Furthermore, Von Lindern et al. [28], comparing BoNT-A and saline solution, showed a significant improvement of local facial pain symptoms in terms of VAS, favoring the use of BoNT-A. On the contrary, Ernberg et al. [29], comparing BoNT-A and saline solution, reported no statistical differences after treatment regarding most outcome measures with the exception of pain on palpation, which decreased 3 months after saline injection (p < 0.05). ...
Temporomandibular disorders (TMDs) are multi-factorial and polysymptomatic pathologies and their management must be customized for every patient. Numerous therapy techniques are available to treat temporomandibular disorders-related muscular discomfort and persistent orofacial pain. Botulinum toxin (BoNT) has emerged as a popular option for patients with myofascial TMD who do not completely recover from their condition after receiving conservative care and medication. A systematic search of the literature, from January 2000 until 1 April 2022, was performed in the MEDLINE (PubMed), Web of Science, and Lilacs databases. The following search terms combination: (temporomandibular disorders) OR (botulinum) OR (toxin) was employed. A total of 357 articles were initially found in the electronic search. After screening, 11 full-text articles satisfied the inclusion criteria. The Cochrane risk of bias tool (RoB 2) tool, which uses seven domains of bias to assess random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment of self-reported outcomes, blinding of outcome assessment of objective measures, incomplete outcome data, selective reporting, and other biases, was employed to analyze randomized controlled trials. The aim of this systematic review of randomized controlled trials is to provide an overview of the use of BoNT for TMDs by comparing the application of BoNT with other therapeutic approaches. BoNT-A could help patients that do not respond to conservative treatments. Low doses are recommended when BoNT-A is considered for persistent orofacial pain related to TMD. Future research should, however, conduct clinical trials with a stricter design. The results of BoNT-A could be confirmed by more randomized controlled trials with larger sample sizes, less bias, and longer follow-up times.
... Cinco ensayos midieron el desenlace de dolor en reposo (288 pacientes) (41,42,43,47,49) . ...
... En cuanto al desenlace número de eventos de bruxismo, fueron tres los ensayos que lo reportaron (41,45,46) , con un total de 58 pacientes. El desenlace de eventos adversos fue reportado por cuatro ensayos (154 pacientes) (41,44,46,49) . Por último, el desenlace evaluación subjetiva del bruxismo del sueño fue reportado por dos ensayos (34 pacientes) (41,46) . ...
... • En la base de datos ClinicalTrials.gov se identificaron dos registros de estudios clínicos en curso que evalúan el uso de Toxina Botulínica en pacientes con bruxismo del sueño (48,49) . ...
Introducción:
El bruxismo del sueño es un comportamiento que se caracteriza por la actividad repetitiva de los músculos masticadores. Varias terapias para el manejo del bruxismo del sueño se centran en la relajación de los músculos involucrados, incluyendo la inyección intramuscular de Toxina Botulínica tipo A (BoNTA). A pesar de que se ha comprobado la efectividad de esta terapia frente al dolor subjetivo, cuando se asocia a bruxismo del sueño, es necesario determinarla frente a desenlaces objetivos, tanto a nivel craneofacial como sistémico. Además, se debe evaluar también la seguridad de esta intervención frente a eventos adversos tales como afecciones estéticas, debilidad masticatoria y pérdida ósea mandibular, entre otros.
Métodos:
Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un meta-análisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE.
Resultados y conclusiones:
Identificamos 11 revisiones sistemáticas que en conjunto incluyeron 9 estudios primarios, de los cuales, 8 corresponden a ensayos aleatorizados. Concluimos que la inyección intramuscular de toxina botulínica tipo A podría disminuir el dolor en reposo, presentar poca o nula diferencia en dolor durante la masticación y mejorar la autoevaluación del bruxismo, pero la certeza de la evidencia es baja. Por otra parte, no es posible establecer con claridad si el uso de Toxina Botulínica Tipo A disminuye el número de eventos de bruxismo, ya que la certeza de la evidencia ha sido evaluada como muy baja. Finalmente y a pesar de la evidencia existente respecto de los potenciales eventos adversos producto de la intervención con Toxina Botulínica Tipo A en los músculos masticatorios, los ensayos clínicos fallan en evaluarlos y reportarlos.
... Primary treatment of myofascial pain in the face may include the use of occlusal splints, supportive patient's exercises, interventions to reduce stress and anxiety, muscle exercises, postural modifications, pharmaceutical therapies (e.g., non-steroidal anti-inflammatory drugs, myorelaxants, benzodiazepines, selective serotonin reuptake inhibitors), alternative therapies, such as acupuncture to reduce symptoms, and botulinum toxin (BoNT) injections [10]. BoNT, which is the exotoxin of a gram-positive bacterium called Clostridium botulinum, acts by blocking the release of acetylcholine in neuro-muscular junctions, thereby reducing the activity of muscles and secretory glands [10,11]. ...
... Favorable effects of BoNT/A on muscle hyperactivity and pain led to its' use in the treatment of TMD-related muscle pain and masticatory myofascial pain [3,4,10,11,13,14]. Although studies have reported significant reductions in muscle pain with BoNT injection, they were focused on 1-to 6-month outcomes. ...
... Numerous studies investigating the efficacy of BoNT/A in relieving TMD-related muscular pain and masticatory muscle myofascial pain have been published in recent years [3,4,10,11,14,16]. While BoNT/A has both pre-synaptic and post-synaptic activity at the neuromuscular junctions, it mainly acts by inhibiting acetylcholine release, without affecting impulse conduction at the nerve terminals [21]. ...
... Approximately 80% of patients respond to conservative treatment with 20% being refractory to first line interventions [186]. In these patients, more invasive treatments need to be used in order to achieve adequate pain relief. ...
... In 2003 von Lindern et al. carried out a randomized controlled study in 90 patients with chronic facial pain caused by hyperactivity of the masticatory muscles, parafunctional movement or hypermobility disorders refractory to conservative treatment [186]. They injected 35 U of onabotulinum toxin in the areas of maximal tenderness and pain in the masseter, temporalis and perygoideus medialis and found that patients treated with BT presented a significant decrease in pain compared to the placebo group (3.2 points versus 0.4 points in the 0-10 numerical scale, respectively). ...
... This improvement occurred along the whole period of follow-up, taking into consideration the minor increase in VAS score at the period of 24 weeks. This coincides with many studies [56,[58][59][60][61][62] that reported improvement in VAS score. These studies reported that VAS score dropped to nearly 3 at the first 4 weeks and 12 weeks of postoperative follow-up period to end with accepted results to the period of 24 weeks postoperatively. ...
... There is a gap in the scientific literature and only a limited number of studies refer to the efficacy of botulinum toxin type A (Botox) and its promising results in the improvement of painful myofascial symptoms [16][17][18][19][20] and although it is not considered a first-choice treatment for the management of TMDs, it could be a therapeutic option in situations where conventional treatments are ineffective. ...
Temporomandibular disorders are a common pathology affecting up to 70% of the population, with a maximum incidence in young patients. We used a sample of twenty patients recruited in the Maxillofacial Surgery Service of the University Hospital of Salamanca (Spain), who met the inclusion criteria, with unilateral painful symptomatology of more than three months’ duration. All patients were randomly treated by intramuscular and intra-articular injections of botulinum toxin (100 U) in eight predetermined points. Pain symptomatology was assessed by the visual analog scale (VAS) at the different locations, together with joint symptomatology, at baseline and six weeks after treatment. Adverse effects were also evaluated. In 85% of the patients, pain upon oral opening improved and 90% showed improvement in pain upon mastication. A total of 75% of the patients reported improvement in joint clicking/noise. Headaches improved or disappeared in 70% of the patients treated. Despite the limitations of the study and the preliminary results, intramuscular and intra-articular infiltrations with botulinum toxin were effective in the treatment of symptoms associated with temporomandibular disorders (TMDs), with minimal adverse effects.
... This treatment works especially well for patients who are prone to bruxism [10,11]. According to a double-blind, controlled placebo, randomized clinical trials with a six-month follow-up period, botulinum toxin type A injections resulted in an improvement of painful symptoms in up to 90% of patients, although the period of pain relief is limited to 8-12 weeks [12]. For many patients, botulinum toxin type A injections are all that they need to manage their chronic MPS. ...
For patients suffering from myofascial pain syndrome (MPS) affecting muscles of mastication, traditional trigger point therapy treatment regimens can prove inconvenient, due to the short duration of pain relief after each injection and expense of repeated visits which are often not covered by insurance. We present a case of a patient treated using an alternative technique that could develop into an additional modality for treating MPS patients who are refractory to conservative treatment. This technique involves identifying and marking the patient’s trigger points and surgically cauterizing each location using a Bovie electrosurgical unit. While traditional trigger point injection therapy for myofascial pain syndrome is a well-described technique with acceptable pain relief expected for a period of 8–12 weeks, this technique provided up to 24 months of adequate pain relief in a patient. While further studies are indicated before widespread adoption can be recommended, this patient’s response suggests that this technique may be useful in offering longer-term pain relief compared with trigger point injection therapy.
... [30] Von Lindern et al. found significant healing with the BT-A application in the symptoms of 90 patients whose myofascial pain was unresponsive to conservative treatment. [31] Yurttutan et al. compared the efficiency of occlusal splints with the BT-A application. They found that the utilization of occlusal splints does not provide additional benefits and there was more improvement in the BT-A application group. ...
Background: Bruxism is defined as recurrent masticatory muscle activity. Although there is not an agreed treatment method for bruxism, the
application of botulinum toxin A (BT‑A) has become a reliable lately. This study aimed to evaluate the correlation between the changes in
masseter muscle thickness and clenching habits in bruxism patients treated with BT‑A. Methods: Twenty‑five patients, 23 females and 2 males,
diagnosed with possible sleep bruxism were included in the study. The Fonseca Anamnestic Index was applied to the patients to determine their
clenching habits and depression levels both before the treatment, and 6 months after it. The masseter muscle thickness was measured using
ultrasonography before the treatment and 3 months and 6 months after the treatment. All the patients were injected with a total of 50 U of BT‑A,
25 U to each masseter. Results: A statistically significant decrease in masseter muscle thickness was observed in the ultrasonography 3 and
6 months after the BT‑A treatment. There was a statistically significant decrease in the Fonseca scores, in which the teeth clenching habits of
the patients were evaluated 6 months after the treatment. Although there was a decrease in the depression levels of the patients 6 months after
the treatment, this difference was not statistically significant. Conclusion: When the results of this study were evaluated, it was seen that the
BT‑A injections are an effective, safe, and side effect‑free method in the treatment of bruxism and masseter hypertrophy.
... Also results of the present study are also in accordance with those of Von Lindern (38) who treated 90 patients (60 verum and 30 placebo) with chronic myofascial pain (caused by hyperactivity of the masticatory muscles and parafunctional movements) with botulinum toxin A injection in a prospective, single-blinded, randomized placebo-controlled study. ...
... Electromyography (EMG) was used during injection in muscles that were difficult to access including the lateral pterygoid muscle which was approached extra-orally in this study. The group reported that pain improved in 80% of the patients, while by the end of the observation period, 17% of patients had to receive a second injection because of recurrent pain [6]. BTX was recommended for patients who did not respond to conservative treatment options such as pharmacologic and physical methods [7]. ...
Objective
Treatment of temporomandibular disc displacement with reduction is controversial. This study assesses the use of an anterior positioning splint with botulinum toxin in the lateral pterygoid muscle (BTX) for such cases.
Methods
Twelve joints were included; groups I and II received BTX injection while group II also received an anterior positioning splint. Pain scores and clicking status were recorded at regular intervals then a postoperative MRI was done after 4 months.
Results
Clinical improvement was noted in both groups. Mean pain scores dropped significantly and clicks in the twelve joints disappeared in 83% of group I and 33% of group II. MRIs showed significant disc position improvement with the higher mean change (1.33 ± 0.76) in group I.
Group I showed better improvement of discal position and only one joint regained a click. Patients of group II reported discomfort from the splint which may have caused psychological distress and so worst pain scores.
Conclusions
Group I showed slightly better results but the cost of BTX injections and the complications of the splint should be kept in mind and the decision of treatment selection made according to each condition.
... Each of these BoNT-A formulations has a unique manufacturing process and contains different excipients (Pickett, 2014), and may be effective to treat different disorders (Baker e Nolan, 2017;Von Lindern et al., 2003). Thus, this study aimed to evaluate different BoNT-A commercially available formulations as possible analgesics in the treatment of an orofacial animal model of pain in mice. ...
The use of botulinum neurotoxin-A (BoNT-A) is an alternative for the management of orofacial pain disorders. Although only Botox has labeled, there are other commercial brands available for use, among them: Dysport, Botulift, Prosigne, and Xeomin. The objective of the present study was to evaluate the possible differences in the antinociceptive effect evoked by different commercially available formulations of BoNT-A in an animal model of inflammatory orofacial pain induced by formalin injection. Male C57/BL6 mice (20–25 g) were submitted to the pre-treatment with five different commercial brands of BoNT-A (Botox, Botulift, Xeomin, Dysport, or Prosigne; with doses between 0.02 and 0.2 Units of Botulinum Toxin, in 20 μL of 0.9% saline) three days prior the 2% formalin injection. All injections were made subcutaneously into the right perinasal area. After formalin injections, nociceptive behaviors like rubbing the place of injection were quantified during the neurogenic (0–5 min) and inflammatory (15–30 min) phases. The treatment using Botox, Botulift, and Xeomin were able to induce antinociceptive effects in both phases of the formalin-induced pain animal model, however, Dysport and Prosigne reduced the response in neither of them. Our data suggest that the treatment using different formulations of BoNT-A is not similar in efficacy as analgesics when evaluated in formalin-induced orofacial pain in mice.
Botulinum toxin (BTX) is becoming widely used as an adjunct to conservative management of myalgia predominant temporomandibular disorders (TMDs) with reports of improved quality of life. There is, however, no consensus on optimal dosage of BTX. Dose regimen varies between clinicians based on previous studies and there is no standard dose protocol that exists in administering BTX for the purpose of TMD management. A survey was sent to members of British Association of Oral and Maxillofacial Surgeons (BAOMS) Temporomandibular Joint Sub-Specialty Interest Group (TMJ SSIG) and an international mailing list of high volume TMJ surgeons (the TMJ Internetwork) to ascertain variation in dose regimens between different clinicians. The survey revealed 41 respondents offered BTX to patients. The masseter muscle group was the most commonly injected site. The majority of respondents (34/41) used Botox®. Less commonly used brands included Dysport® and Xeomin®. Botox® doses varied between 30 units to 100 units, whilst Dysport® doses ranged from 50 units to 300 units per muscle. The number of injection sites per muscle also varied amongst respondents. This survey demonstrates the wide variation in practice amongst clinicians with respect to BTX administration. To ensure optimal dose and response titration, it is important further studies and evidence-based research is carried out to standardise the use of BTX in TMDs where applicable.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
OnabotulinumtoxinA (ONA), trademarked under the brand name Botox, is a widely studied botulinum neurotoxin currently used for diverse cosmetic and noncosmetic therapeutic treatments. ONA was the first in a growing market of injectable neuromodulators to be studied for medical use. First introduced to the cosmetic marketplace in 2002 by the U.S. Food and Drug Administration for clinical indication of wrinkle correction for glabellar frown lines, ONA has proven to be an invaluable tool in the armamentarium of aesthetic medicine. The most commonly approved dermatologic uses of ONA include facial rhytidosis and hyperhidrosis with ongoing phase 2B studies for masseter hypertrophy. Nondermatologic applications include temporomandibular disorders, strabismus, cervical dystonia, blepharospasm, spasticity, migraines, overactive bladder, and incontinence. Off‐label uses of ONA are well studied in skin disorders, such as rosacea, and other indications, such as Frey's syndrome, and depression. Further, multiple studies have illustrated an improvement in quality of life and self‐esteem with ONA treatment. The favorable side effect profile with minimal adverse effects reinforces that ONA is a safe and effective treatment option with a diverse portfolio of clinically accepted applications.
Classical surgical techniques for the treatment of pronounced retroposition of the mandible with or without temporomandibular joint (TMJ) pathologies have a significant recurrence rate. In extreme cases of this pathology, alloplastic TMJ reconstruction in combination with other procedures of dysgnathic surgery enables a safe and stable correction of mandibular malocclusions and simultaneous reconstruction of the TMJ, albeit with inherent invasiveness and risk profile. An alternative sequential treatment concept for three-dimensional distraction of the mandible in combination with Le Fort I osteotomy and Wing osteotomy in cases of pronounced mandibular retroposition and/or hypoplastic TMJs is presented. In approximately 900 cases operated on with the described technique, no clinically relevant recurrence rate has been observed to date. TMJ replacement that may become necessary later on is not compromised by the operations presented here.
Functional disorders of the temporomandibular joint (TMJ) lead to joint noises and pain during function, jaw movement alterations, and sudden occlusal disturbances, closed lock, or lockjaw. Causes include dysfunction of masticatory musculature, disk dislocation or perforation, and degenerative changes of intraarticular soft and hard tissues. Because of the high adaptive potential of the TMJ, most of these are self-limiting; progression is not inevitable. Invasive therapy may be indicated in progressive cases lacking adaptation, and when the patient desires a shorter duration of complains during the adaptation phase. A proven spectrum of minimally invasive or open surgery methods are available. However, in terms of postoperative pain symptoms, hyperfunction of the jaw musculature seems to be the most important restrictive condition.
Botulinum toxin is a neurotoxin which is produced by the Clostridium botulinum bacteria. It is an anaerobic, gram-positive, spore-forming rod-shaped bacteria which is commonly found in soil, on plants, in water and in the intestinal tracts of animals. All the serotypes of botulinum toxin interfere with neural transmission by blocking the release of acetylcholine. The use of botulinum toxins has revolutionised the treatment of various ophthalmic spastic disorders, Orofacial pain conditions, facial dystonia and periocular wrinkles. A precise knowledge and understanding of the functional anatomy of the mimetic muscles is absolutely necessary to correctly use botulinum toxins in clinical practice. This article is an effort to understand Botulinum toxin and its applications in head and neck.
This chapter summarizes what is known about temporomandibular disorders (TMD) pain problems with implications for orthodontics. It points out significant questions and issues which may not be answered or guided by the highest level of evidence yet, but where patient‐based concerns and clinical experience must be used in the prudent management of individual patients. The DC/TMD system uses stringent and well characterised criteria for the most usual types of manifest TMD problems, and the extensive translation to many languages helps to disseminate the system so that both researchers in the field and clinicians treating patients can benefit from a consensus on the terminology. The management strategies for TMD pain follow the same principles of management of other musculoskeletal pain conditions, that is, there can be physical, pharmacological and psychological oriented strategies. Systematic studies on the efficacy of psychological management of TMD pain are rather scarce.
Objective An evidence-based review on the safety and efficacy of botulinum toxin type-A (BoNTA) in orofacial conditions, focusing on the therapeutic applications and role of BoNTA as an adjuvant treatment. Data source and selection Data was collected using PubMed (Medline), Cochrane Library of Systematic Reviews and Cochrane Central Register of Controlled Trials electronic databases. Having satisfied the search parameters, 32 studies for therapeutic applications and 26 for BoNTA as an adjunctive treatment were included. The quality of relevant studies was assessed using the Best Evidence Topics (BETs) Critical Appraisal Tool. Data extraction The highest level of evidence (LOE) behind BoNTA safety and efficacy was for wound healing and scar management in the orofacial surgery context, where BoNTA was presented as an adjunctive modality. Level-I evidence was controversial for temporomandibular disorders and bruxism. However, it showed promising results for painful temporomandibular disorders of myogenic origin refractory to conservative therapies, and to decrease muscle contraction intensity in sleeping bruxism. There was only one level-II study for persistent recurrent aphthous stomatitis. Data showed limited level-III evidence for orofacial pain conditions (temporomandibular joint recurrent dislocation and pain, burning mouth syndrome or atypical odontalgia), oral cancer complications, or as an adjuvant to maxillofacial and orthognathic surgeries. Benefits of BoNTA in prosthodontics had weak level-IV evidence. No evidence was found among the periodontology field. Conclusion There is growing evidence to support the safety and efficacy of BoNTA in the investigated orofacial pathological conditions, with high levels of satisfaction from the patient and clinician perspective. However, there are some inconsistencies and limited high-quality evidence available. Well-designed controlled clinical trials are necessary to evaluate long-term safety, efficacy and cost-effectiveness before BoNTA is widely adopted with irrefutable evidence-based clinical guidelines.
Objective: A systematic review was performed to evaluate if the use of botulinum toxin was able to reduce the intensity of myofascial pain compared to other treatments in adult patients. Material and Methods: A comprehensive search was carried out in the MEDLINE via Pub-Meb, Scopus, Web of Science, LILACS, BBO and Cochrane Library. In addition, the gray literature was also researched. The risk of bias tool from the Cochrane Collaboration was used by two independent reviewers for quality assessment of the studies. Results: A total of 4372 studies were identified, 9 remained in qualitative study, 8 of these studies were considered at “unclear” risk of bias and just one study was “low” risk of bias in the key domains. Only two studies presented similar data to be included in the meta-analysis. Both studies evaluated the pain relief used the botulinum toxin (BTX-A) versus saline solution. The meta-analysis demonstrated that after 3 months follow-up the pain relief was 15.70 (95 % confidence interval [CI] = 0.80 to 30.61; p = 0.04). Conclusion: The BTX-A reduced the intensity of myofascial pain compared to saline solution in adults after 3 months. However, further studies should be conducted to corroborate this finding.
Purpose:
The aim of this study was to analyze the clinical outcome of the use of botulinum toxin type A (BTX) intramuscular injections to the head and neck, particularly the masticatory muscles of patients with temporomandibular disorder (TMD).
Methods:
The medical records of all patients who had received intramuscular BTX injections between 2005 and 2018 at Päijät-Häme Central Hospital, Lahti, Finland were analyzed retrospectively. Gender, age, previous medical history, number of injections, injection areas, and therapeutic results were collected and analyzed. The outcome was divided into three categories based on the patients' subjective reports: not beneficial, beneficial, and highly beneficial.
Results:
A total of 68 patients had received intramuscular BTX injections in our unit for TMD symptoms. Clinical effectiveness could be analyzed from 63 patients. Overall, 87% of them reported favorable outcomes. 8 (13%) reported BTX injections as not beneficial, 15 (24%) as beneficial, and 40 patients (63%) as highly beneficial.Most patients had already received conventional treatment with an occlusal splint (93%) combined with pain medication (60%) in the primary care units before they were referred to our hospital.There were 59 (83%) female patients, and they responded better to BTX therapy than the male patients: 91% versus 57% (P value = 0.04). Average age at the first BTX injection visit was 44.6 years (range 17.8-77.2). Most commonly (65%), BTX was divided bilaterally to the masseter and temporalis muscles.
Conclusions:
BTX injections had good therapeutic outcomes for our TMD patients. However, most patients require multiple injection visits.
creative commons attribution noncommercial License. Which allows others to remix, tweak, and build upon the work non commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. Abstract Objectives: The purpose of this prospective observational study was to evaluate the effectiveness of botulinum Toxin A in reducing myofascial pain in masseter muscle associated with temporomandibular joint with the aid of visual analogue scale, algometry and surface electromyography in patient's refractory to conservative management. Material and Method: The study was a prospective observational study and was done on 12 participants.
Clostridial neurotoxins, tetanus toxin (TeTx) and the seven related but serologically distinct botulinal neurotoxins (BoNT/A to BoNT/G), are potent inhibitors of synaptic vesicle exocytosis in nerve endings. Recently it was reported that the light chains of clostridial neurotoxins act as zinc-dependent metalloproteases which specifically cleave synaptic target proteins such as synaptobrevin/VAMPs, HPC-1/syntaxin (BoNT/C1), and SNAP-25 (BoNT/A). We show here that BoNT/E, like BoNT/A, cleaves SNAP-25, as generated by in vitro translation or by expression in Escherichia coli. BoNT/E cleaves the Arg180-Ile181 bond. This site is different from that of BoNT/A, which cleaves SNAP-25 between the amino acid residues Gln197 and Arg198. These findings further support the view that clostridial neurotoxins have evolved from an ancestral protease recognizing the exocytotic fusion machinery of synaptic vesicles whereby individual toxins target different members of the membrane fusion complex.
The effects of botulinum toxin‐A was compared on both extrafusal and intrafusal muscle fibers in the biceps femoris of Wistar rats. Four days after injection, no action potentials were elicited with stimulation single‐fiber electromyography on the injected side. Fourteen days after injection, jitter became measurable and these values were increased on the injected side. Extrafusal muscle fibers began to atrophy on the 4th day and this continued to the 14th day postinjection. Atrophy was also evident and progressive in intrafusal muscle fibers. Increased terminal innervation ratios, end‐plate spread of cholinesterase, and increased density of very small myelinated fibers in large intramuscular nerves were observed 14 days postinjection. Both extrafusal and intrafusal fibers are cholinergically innervated, and both were progressively affected by botulinum toxin, perhaps varying in degree only. In addition to partial denervation, Botulinum toxin effects in dystonia may also be related to modified spindle afferent discharge. © 1996 John Wiley & Sons, Inc.
Purpose:
To investigate the effects of botulinum toxin type A (botulinum A toxin) on the autonomic and other nonadrenergic, noncholinergic nerve terminals.
Methods:
The effects of botulinum A toxin on twitch contractions evoked by electrical field stimulation (EFS) were studied in isolated albino and pigmented rabbit iris sphincter and dilator muscles using the isometric tension recording method.
Results:
Botulinum A toxin inhibited the fast cholinergic and slow substance P-ergic component of the contraction evoked by EFS in the rabbit iris sphincter muscle without affecting the response to carbachol and substance P. These inhibitory effects were more marked in the albino rabbit than in the pigmented rabbit. Botulinum A toxin (150 nmol/L) did not affect the twitch contraction evoked by EFS in the rabbit iris dilator muscle.
Conclusions:
These data indicated that botulinum A toxin may inhibit not only the acetylcholine release in the cholinergic nerve terminals, but also substance P release from the trigeminal nerve terminals of the rabbit iris sphincter muscle. However, the neurotoxin has little effect on the adrenergic nerve terminals of the rabbit iris dilator muscle. Furthermore, the botulinum A toxin binding to the pigment melanin appears to influence the response quantitatively in the two types of irides.
Purpose: To investigate the effects of botulinum toxin type A (botulinum A toxin) on the autonomic and other nonadrenergic, noncholinergic nerve terminals.Methods: The effects of botulinum A toxin on twitch contractions evoked by electrical field stimulation (EFS) were studied in isolated albino and pigmented rabbit iris sphincter and dilator muscles using the isometric tension recording method.Results: Botulinum A toxin inhibited the fast cholinergic and slow substance P-ergic component of the contraction evoked by EFS in the rabbit iris sphincter muscle without affecting the response to carbachol and substance P. These inhibitory effects were more marked in the albino rabbit than in the pigmented rabbit. Botulinum A toxin (150 nmol/L) did not affect the twitch contraction evoked by EFS in the rabbit iris dilator muscle.Conclusions: These data indicated that botulinum A toxin may inhibit not only the acetylcholine release in the cholinergic nerve terminals, but also substance P release from the trigeminal nerve terminals of the rabbit iris sphincter muscle. However, the neurotoxin has little effect on the adrenergic nerve terminals of the rabbit iris dilator muscle. Furthermore, the botulinum A toxin binding to the pigment melanin appears to influence the response quantitatively in the two types of irides.
Purpose: To review literature regarding clinical response to injections of botulinum toxin type A for a variety of painful disorders of involuntary muscular contraction. Methods: A MEDLINE search for the headings 'botulinum toxin', 'myofascial pain' and 'pain' was performed for the period 1966 to September 1997. Results: Eighteen references including 463 subjects were generated. Seven studies included 'pain' or 'myofascial pain' within the article title, while the remaining references reported pain response within the context of treatment for underlying spasticity, cervical dystonia, fibromyalgia, focal dystonia, hemifacial spasm, painful dystonia of Parkinson's disease, pain of chronic pancreatitis, writer's cramp and masseteric hypertrophy. Results of pain response in the cited studies were favorable in all except in fibromyalgia and chronic pancreatitis. The authors discuss instruments to measure pain intensity and physical functioning for future research and introduce a new instrument that includes self-reported pain assessment linked to joint position. Conclusion: Evidence suggests that BTX-A effectively reduces painful muscular contractions associated with a variety of neurologic conditions. Further research is needed to define conditions in which injections will be most effective.
For many years, the use of botulinum toxin in the management of dystonia and associated conditions, has been recognized as
not only having a beneficial effect on muscle tone and activity, but also to be associated with significant and prolonged
pain relief. It is difficult to understand how this effect could be mediated solely on the basis of the toxin’s well-known
property of chemodenervation of motor end plates. A second mode of action is demonstrated, in which effects on the muscle
spindle play a prominent role, and which may enhance analgesia. A hypothesis is presented that a toxin degradation product
may provide pain relief by mechanisms yet to be elucidated.
Intramuscular injections of botulinum toxin type A (Oculinum) is used to treat strabismus and focal dystonias affecting orofacial muscles. However, the toxin-induced morphological changes that underlie the therapeutic alterations of tone in the muscles of mastication have not been described. In this study, paired intramuscular injections of botulinum toxin (10 units) were made in three adult monkeys (Macaca fascicularis) allowed to survive 14, 28 and 63 days. Another monkey received multiple injection-pairs over 84 days. Animals were killed by deep pentobarbital anaesthesia before transcardiac perfusion-fixation. Tissue sampled from comparable regions of the injected masseter, the uninjected masseter and an uninjected animal was processed for ultrastructural analysis. Few changes were found 14 days post-injection. However, muscle fibres showed myofibrillar dissolution, aberrations in the Z-line, and enlarged mitochondria in the region of the I-band by 28 days. In the 63-day and 84-day animals, the injected muscle was considerably smaller than the uninjected, contralateral muscle. Regions of the injected muscle contained fibres with markedly reduced cross-sectional area. Internalization of myonuclei, loss of myofibrillar organization, and helical complexes were common. Toxin-induced changes, though similar to those that follow denervation by axotomy, were not accompanied by degeneration of neuromuscular junctions. Instead, morphological evidence for axonal sprouting in the region of the neuromuscular junction, possibly contributing to functional recovery, was seen as early as 14 days in toxin-treated muscles.
Masticatory muscle hyperactivity appears to have an important role in temporomandibular disorders. A pathophysiological model for masticatory muscle hyperactivity is proposed that is centrally mediated, yet maintains support for present peripheral causes and therapies. In this hypothesis, masticatory muscle hyperactivity represents a mild extrapyramidal disorder distantly related to orofacial dyskinesias. Experimental evidence suggests a neurotransmitter imbalance in the basal ganglia, involving dopaminergic preponderance, or cholinergic and GABA-nergic hypofunction as the underlying cause.
Dystonia is a neurologic disorder characterized by abnormal, involuntary movements causing twisting and turning postures; it is postulated to be a disorder of central motor processing. The dystonias, when classified by region of the body involved, have been characterized as focal, segmental, and generalized. Focal dystonia can affect jaw mechanics, leading to forceful contraction of the jaw muscles and resulting in inappropriate deviation of the jaw. Localized injections of botulinum toxin have been used successfully in the management of other focal or segmental dystonias. We have treated 20 oromandibular dystonia patients with botulinum toxin. Six patients had only jaw and tongue involvement; 11 had blepharospasm and jaw involvement; and three had jaw involvement as part of a more generalized dystonia. Five patients had been diagnosed originally and treated as having temporomandibular joint syndrome. All but one of the patients had improvement of their symptoms with the toxin injections. The patients averaged 47% improvement with the injections.
Botulinum A toxin (Botox) is used for the treatment of many muscular dystonias. However, the relief of the sustained and abnormal postures induced by Botox administration is not fully explained. In this work the possibility was considered that Botox can produce a block not only at the alpha motor endings, but also at the gamma motor endings, consequently reducing the spindle inflow to the alpha motoneurons, which have a great role in maintaining the tonic myotatic reflex. Jaw muscle spindle discharge was recorded before and after Botox injection in the deep masseter muscle. The drug consistently reduced the spindle afferent discharge. Such an effect is suggested to be direct on gamma endings as: i) muscle tension was not modified by Botox during the recording time; ii) saline administration never changed the spindle discharge. The Botox effect on muscle spindles suggests that the relief from dystonias could be due not only to a partial motor paralysis, but also to a decrease of the reflex muscular tone.
The effects of botulinum toxin-A was compared on both extrafusal and intrafusal muscle fibers in the biceps femoris of Wistar rats. Four days after injection no action potentials were elicited with stimulation single-fiber electromyography on the injected side. Fourteen days after injection, jitter became measurable and these values were increased on the injected side. Extrafusal muscle fibers began to atrophy on the 4th day and this continued to the 14th day postinjection. Atrophy was also evident and progressive in intrafusal muscle fibers. Increased terminal innervation ratios, end-plate spread of cholinesterase, and increased density of very small myelinated fibers in large intramuscular nerves were observed 14 days postinjection. Both extrafusal and intrafusal fibers are cholinergically innervated, and both were progressively affected by botulinum toxin, perhaps varying in degree only. In addition to partial denervation, Botulinum toxin effects in dystonia may also be related to modified spindle afferent discharge.
To highlight some clinical and physiological features related to treatment with botulinum toxin type A (BTX-A) injections for focal dystonia that may suggest an effect through efferent (alpha motoneuron) and afferent pathways.
This review is based on published clinical and physiological studies as well as personal experience regarding the effect of BTX-A in focal dystonia.
Long or short lag period between BTX-A injections and clinical improvement, remote effect, an effect on the basic physiological characteristics of dystonia, poor correlation between the local weakness and the clinical improvement and alleviation of pain are clinical observations which are difficult to explain on the basis of the known effect of BTX-A on the neuromuscular junction of the alpha motoneuron. These observations as well as recent scientific reports are used to discuss a hypothesis that in addition to its effect as local muscle relaxant, BTX-A acts at the level of the central nervous system (CNS) for 'reorganization'. Such an effect on CNS activity can be mediated through afferent pathways coming from the injected site--possibly originated in muscle spindles. Its effect through afferent pathways on the CNS may be considered as a long-term 'sensory trick'.
Purpose: The aim of this study was to evaluate the response of patients with temporomandibular disorders to Botulinum toxin A (BTX-A) therapy. Methods: The 15 subjects enrolled in this uncontrolled study were diagnostically categorized and treated with 150 units of BTX-A. Both masseter muscles received 50 units each under eletromyographic (EMG) guidance. Similarly, both temporalis muscles were injected with 25 units each. Subjects were assessed at 2-week intervals for 8 weeks. Outcome measures included subjective pain by visual analog scale (VAS), measurement of bite force, interincisal opening, tenderness to palpation, and a functional index based on multiple VAS. Results: All mean outcome measures, with the exception of bite force, showed a significant (P = .05) difference between the preinjection assessment and the four follow-up assessments. No side effects were reported. Conclusions: BTX-A injections produced a statistically significant improvement in four of five measured outcomes, specifically pain, function, mouth opening, and tenderness. No statistically significant changes were found in mean maximum voluntary contraction or in paired correlation of factors such as age, sex, diagnosis, depression index, or time of onset.
For many years, the use of botulinum toxin in the management of dystonia and associated conditions, has been recognized as not only having a beneficial effect on muscle tone and activity, but also to be associated with significant and prolonged pain relief. It is difficult to understand how this effect could be mediated solely on the basis of the toxin's well-known property of chemodenervation of motor end plates. A second mode of action is demonstrated, in which effects on the muscle spindle play a prominent role, and which may enhance analgesia. A hypothesis is presented that a toxin degradation product may provide pain relief by mechanisms yet to be elucidated.
Temporomandibular disorders (TMDs) affect the face and jaws, and cause chronic pain and dysfunction in many people. As in other conditions involving the musculoskeletal system, controlling the myogenous component is an integral part of treatment. In this study, we evaluated subjective and objective responses to treatment with botulinum toxin A (BTX-A) in a group of 46 patients with TMDs.
46 subjects with TMD were enrolled in this uncontrolled study and treated with BTX-A 150U. Both masseter muscles were injected with 50 U each and both temporalis muscles with 25 U each under electromyographic guidance. Subjects were assessed at two-week intervals for eight weeks. Outcome measures included subjective assessment of pain by visual analogue scale (VAS), measurement of mean maximum voluntary contraction (MVC), interincisal oral opening, tenderness to palpation, and a functional index based on multiple VAS. Medians of the data were taken for each outcome measure at each time point and subjected to Duncan's multiple range test.
There were significant (P<0.05) differences in all median outcome measures between the pre-treatment assessment and the four follow-up assessments except for MVC. Although MVC was significantly reduced midway through the study, it had returned to pretreatment values by the final two assessments. All other outcome measures remained significantly different from the pretreatment findings. Paired correlation of variables including age, sex, diagnosis, depression index, and time of onset showed no significant differences.
BTX-A injections produced significant improvements in pain, function, mouth opening, and tenderness to palpation. MVC initially diminished then returned to the initial values. Although the study was uncontrolled, the results strongly suggest that BTX-A reduces severity of symptoms and improves functional abilities for patients with TMD and that these extend beyond its muscle-relaxing effects.
To investigate the effects of botulinum toxin type A(botulinum A toxin) on the autonomic and other non-adrenergic, non-cholinergic nerve terminals.
The effects of neurotoxin on twitch contractions evoked by electrical field stimulation (EFS) were studied in isolated rabbit iris sphincter and dilator muscles using isometric tension recording.
Botulinum A toxin(150 nM) inhibited the fast cholinergic and slow substance P-ergic component of contraction evoked by EFS in the rabbit iris sphincter muscle without affecting the response to carbachol and substance P. Botulinum A toxin(150 nM) did not affect the twitch contraction evoked by EFS in the rabbit iris dilator muscle.
These data indicated that botulinum A toxin may inhibit not only the acetylcholine release in the cholinergic nerve terminals, but also substance P release from the trigeminal nerve terminals of the rabbit iris sphincter muscle. However, neurotoxin has little effect on the adrenergic nerve terminals of the rabbit iris dilator muscle.
Temporomandibular disorder (TMD) is a collective term used to characterize a heterogeneous group of conditions involving the temporomandibular joint (TMJ) and its contiguous tissues. Although the pathologies behind TMDs have not been completely explained, the symptoms associated with these disorders are similar and are most commonly manifest as pain in the orofacial region. In preliminary studies, botulinum toxin has been used successfully to treat various pain syndromes, including TMDs. Because of the complex nature of TMDs and proximity of affected muscles to facial nerves, correct injection technique and appropriate dosing guidelines are very important for successful results. This article describes common TMDs and their treatment with botulinum toxin. Dosing guidelines and illustrations of affected muscles and target injection sites are provided.
The social character of TMJ dysfunction
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Was leistet die funktionelle Therapie und wo findet sie ihre Grenzen? Dtsch Zahnä Z 40:165, 1985 11. Schulte W: Zur funktionellen Behandlung der Myoarthropa-thien des Kauorgans Ein diagnostisches und physiotherapeutis-ches Programm
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Graber G: Was leistet die funktionelle Therapie und wo findet sie ihre Grenzen? Dtsch Zahnä Z 40:165, 1985 11. Schulte W: Zur funktionellen Behandlung der Myoarthropa-thien des Kauorgans Ein diagnostisches und physiotherapeutis-ches Programm. Dtsch Zahnä Z 25:422, 1970
Botulinum A toxin effect on jaw muscle spindles Guyer BM: Mechanism of botulinum toxin in the relief of pain
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Filippi GM, Errico P, Santarelli R, et al: Botulinum A toxin effect on jaw muscle spindles. Acta Otolaryngol (Stockh) 113:400, 19. Guyer BM: Mechanism of botulinum toxin in the relief of pain. Curr Rev Pain 3:427, 1999
Erscheinungsformen muskulärer Hyperaktivität im Kiefer und Gesichtsbereich
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Reich RH, Roßbach A: Erscheinungsformen muskulärer Hyperaktivität im Kiefer und Gesichtsbereich. Dtsch Zahnärztl Z
43:11, 1988
Botulinum toxin for the treatment of oromandibulolingual (OMD) dystonia
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Brin MF, Blitzer A, Green PE, et al: Botulinum toxin for the
treatment of oromandibulolingual (OMD) dystonia. Neurology
S1:294, 1989
- W Schulte
Schulte W: Zur funktionellen Behandlung der Myoarthropathien des Kauorgans Ein diagnostisches und physiotherapeutisches Programm. Dtsch Zahnärztl Z 25:422, 1970
Was leistet die funktionelle Therapie und wo findet sie ihre Grenzen?
- Graber
Graber G: Was leistet die funktionelle Therapie und wo findet
sie ihre Grenzen? Dtsch Zahnärztl Z 40:165, 1985
Interventional neurology
- Brin
Botulinum toxin for the treatment of oromandibulolingual (OMD) dystonia
- Brin
Treatment of painful muscle syndrome with botulinum toxin
- Childers
The development of BOTOX
- Aoki
Zur funktionellen Behandlung der Myoarthropathien des Kauorgans Ein diagnostisches und physiotherapeutisches Programm
- Schulte