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TMJ News Bites
July 2011
Volume 3, Issue 4 |
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Botox & Myofascial TMJ Pain Study
Our sincere thanks to Dr. Susan Herring of the University of Washington in Seattle for providing the following summary of a recent article in the professional journal, Pain.
Ernberg M., Hedenberg-Magnusson B., List T., Svensson P.
In press, Pain (2011), doi:10.1016/j.pain.2011.03.036.
Botox blocks the release of neurotransmitters from nerve endings. Although chiefly used to stop muscle contraction, it might also relieve pain by preventing nerves from releasing inflammatory molecules. This clinical trial investigated whether Botox injection of the masseter was an effective treatment for patients with persistent myofascial TMJ pain.
The 21 patients (19 female) all met rigorous criteria and were recruited from 4 Danish and Swedish clinics. The study was very well-controlled in that (1) patients served as their own controls and were injected twice, once with Botox and once with saline, but in random order (crossover design) and (2) investigators as well as subjects were blinded as to which substance was injected (double blinding). Patients were carefully examined for pain and other variables 1 month and 3 months after the injections.
Side effects reported in the first week after injections included headache and fatigue, but were similar for Botox and saline; side effects were gone by 1 month. This suggests that subjects were not able to tell which injection was the Botox.
Surprisingly, pain intensity was reduced after both Botox and saline injections, although more so for Botox. However, the number of patients that experienced significant (defined as 30% decrease) pain reduction was about the same for both treatments.
The investigators concluded that there was a strong placebo effect, which means that less well-controlled studies may not be valid. While there was a slightly better outcome for Botox than for saline, it was small and was not experienced by all patients. The authors recommended against the use of Botox as an adjunct to conservative treatment of persistent myofascial pain on the basis of its high cost and lack of efficacy.
Botox's Effect on the Jaw Joint
Dr. Susan Herring and her colleagues presented their own research findings at the International Association for Dental Research (IADR) meeting in March of this year. Dr. Herring preparing the following lay summary for TMJ News Bites readers:
Rafferty K., Liu Z-J., Ye W., Slamati A. ,Gross T., Herring S., Oral Presentation at the 89th General Session & Exhibition of the IADR, San Diego, CA, March 19, 2011.
Botox works by inactivating the nerve endings that cause muscles to contract, thus paralyzing the muscle. The paralysis usually lasts for a few months, although the muscles may remain visibly small for longer times. Some providers feel that treating the jaw muscles of TMD patients with Botox could be helpful even if the muscles are not in spasm. For example, it has been argued that the jaw muscles place loads on the TMJ, and if these loads are temporarily removed, the joint might have a chance to recover.
One possible worry about unloading joints, however, is that bone strength might be lost from the unloaded area, similar to astronauts losing bone strength while in space. Because bone is rebuilt slowly, the jaw joint might actually lose needed structure.
To test this idea an animal study was carried out. In 40 adult female rabbits, one masseter muscle was injected with either saline or Botox, with a dose adjusted to be comparable to a human dose. The muscles and mandible were examined 4 weeks later, when the masseter would still have been affected by the Botox, and 12 weeks later, when the muscle was expected to have recovered.
The rabbits did not experience problems in chewing and seemed comfortable. As expected, the Botox-injected masseter muscles were atrophied at 4 weeks. They were larger at 12 weeks but still statistically smaller than the other side. From this and other evidence, the experiment was successful in unloading the jaw. However, this unloading did have adverse effects on bone content, especially for the mandibular condyle (the mandibular part of the TMJ) on the Botox-injected side. On average, 40% of bone area was lost from the head of the mandibular condyle 4 weeks after injection, and after 12 weeks the bone of the condylar head was still depleted by 22%. The bone loss occurred in the porous bone in the internal region of the condyle, which has limited capacity to regenerate once it is lost.
In conclusion, Botox in the masseter caused an osteoporotic condition in the TMJ of rabbits, raising some concern that this treatment might not be healthy for the joint in the long term.
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The TMJA seeks opportunities to bring TMJ patient concerns to the attention of policy makers and to advance scientific research.
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TMJA's Sixth Scientific Meeting:
A Paradigm Shift
The TMJA held its 6th international scientific conference June 5-7, at the Federation of Societies for Experimental Biology Conference Center in Bethesda, MD.
The topic: Comorbid Chronic Pain Conditions—Mechanism, Diagnosis and Treatments—followed up on the Association’s scientific meeting of 2008, which initially explored the topic of comorbidities. In the interim, there has been further evidence that TMJ patients often experience other chronic pain conditions, including endometriosis, fibromyalgia, chronic fatigue syndrome, migraine and chronic headaches, irritable bowel syndrome, chronic pelvic pain, vulvodynia, and interstitial cystitis.
The meeting was a resounding confirmation that there must be some underlying mechanism that links the conditions in question, and that the answer may lie in the nervous system. Instead of looking for clues in the end organ—the jaw, the intestine, the reproductive tissues—the focus should be on how the nervous system has changed because of chronic pain, becoming hypersensitive and dysfunctional. This is a paradigm shift and attendees agreed it should inform how future research should be conducted.
The meeting was unique in bringing together experts from diverse fields, including specialists who treat the various conditions, pain researchers, and other basic and clinical scientists, as well as patients. Following the formal presentations, attendees developed recommendations that will be disseminated to the research community.
TMJA will publish a summary for the general public along with the recommendations in a forthcoming issue of TMJ Science.
Now that the pain issue has been brought to the forefront, the TMJA will explore the interactions between the TM joint and the nervous system that give rise to chronic pain.
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Institute of Medicine Report: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research |
HOPE FOR PAIN CARE FOR TMJ PATIENTS
Your Association in Action
The TMJA joined consumers, health professionals, advocates, and media on June 29 in Washington D.C. for the Institute of Medicine (IOM) press conference and the release of the executive summary and full report, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research. This event attracted considerable media attention to the 116 million Americans who experience chronic painful conditions, and its high economic toll, costing the nation up to $635 billion annually. AP, CNN, Reuters, Time, US News & World Report and many others covered this story.
The Patient Protection and Affordable Care Act of 2010 called for the Institute of Medicine of the National Academy of Science to explore the public health significance of pain in the United States. The IOM report spells out the IOM committee's recommendations for improving pain care.
Terrie Cowley, President of the TMJA, provided testimony and answered questions from IOM committee members for 45 minutes at the first of several public meetings held around the country to hear what the public had to say about pain research, treatment and care. The TMJA is pleased that Terrie was quoted four times in the IOM report− listed as a patient advocate.
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Quotes from the Preface
Because the Preface of the IOM report is such an eloquent statement of the issues and experiences of the Committee Chair and Vice-Chair, as well as their vision for the future, we are providing the following excerpts:
“Protection from and relief of pain and suffering are a fundamental feature of the human contract we make as parents, partners, children, family, friends, and community members, as well as a cardinal underpinning of the art and science of healing. Pain is part of the human condition; at some point, for short or long periods of time, we all experience pain and suffer its consequences. While pain can serve as a warning to protect us from further harm, it also can contribute to severe and even relentless suffering, surpassing its underlying causes to become a disease in its own domains and dimensions. We all may share common accountings of pain, but in reality, our experiences with pain are deeply personal, filtered through the lens of our unique biology, the society and community in which we were born and live, the personalities and styles of coping we have developed, and the manner in which our life journey has been enjoined with health and disease…”
“…While we came to this study with our own expectations, we have recognized as a consequence of our shared efforts that the magnitude of the pain suffered by individuals and the associated costs constitute a crisis for America, both human and economic. We recognize further that approaching pain at both the individual and the broader population levels will require a transformation in how Americans think and act individually and collectively regarding pain and suffering. We believe this transformation represents a moral and national imperative…” Click here to read more.
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