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Title Efficacy of Botulinum Toxin In Treating Myofascial Pain And TMD
Clinical Question For an otherwise healthy adult diagnosed with myofascial pain, how does botulinum toxin as a therapeutic agent compare to other strategies such as occlusal splints and self-management therapies?
Clinical Bottom Line Several randomized controlled studies have shown the effectiveness of botulinum toxin in reducing myofascial pain and other related temporomandibular joint disorders with transient adverse side effects if any. Studies did not include comparisons of botulinum toxin treatment with occlusal guards. (See Comments on the CAT below)
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 17560141Inde/20074 Randomized Control Studies were evaluated in this studySystematic Review
Key resultsOne RCT showed the following results with regards to myofascial pain: “With respect to efficacy, 4 weeks after treatment, 91% of patients receiving botulinum toxin A had improved facial pain symptoms. Mean improvement based on a visual analogue scale (VAS) for pain was significantly better in the botulinum toxin group compared with the saline group (3.2 points versus 0.4 points, P < .01). Patients with greater initial pain (>6.5 points on the VAS) showed a greater improvement than those with less initial pain.” The article concluded that, “[botulinum toxin] appears to be safe and effective in treating facial pain attributable to chronic facial pain associated with masticatory hyperactivity, although more randomized trials should be performed to confirm these findings.”
#2) 19241799Venancio/200945 patients with myofascial painRandomized Controlled Trial
Key resultsThe study examined 45 patients with headaches related to myofascial pain that could be reproduced by activating trigger points. The patients were randomly assigned to 3 groups: dry needling, injections of 0.25% Lidocaine and injections of botulinum toxin. Patients were assessed during a 12 week period and the levels of pain intensity, frequency and duration, local post injection sensitivity, duration of relief, and the use of rescue medication were examined. Statistically, all the groups showed favorable results (p < 0.05) except for the use of rescue medication and local post injection sensitivity (botulinum toxin was better). The article concludes that, “Considering its reduced cost, lidocaine could be adopted as a substance of choice, and botulinum toxin should be reserved for refractory cases, in which the expected effects could not be achieved, and the use of a more expensive therapy would be mandatory.”
#3) 18468272Guarda-Nardini/200820 patients with a clinical diagnosis of bruxism and myofascial painRandomized Controlled Trial
Key results20 patients were randomly divided into groups receiving botulinum toxin injections to treat myofascial pain and the other receiving a placebo of saline injections. “A number of objective and subjective clinical parameters (pain at rest and during chewing; mastication efficiency; maximum non-assisted and assisted mouth opening, protrusive and laterotrusive movements; functional limitation during usual jaw movements; subjective efficacy of the treatment; tolerance of the treatment) were assessed at baseline time and at one week, one month, and six months follow-up appointments. Descriptive analysis showed that improvements in both objective (range of mandibular movements) and subjective (pain at rest; pain during chewing) clinical outcome variables were higher in the Botox treated group than in the placebo treated subjects.” Due to the small sample size, more studies should be conducted to deem the results conclusive.
Evidence Search Search: botulinum toxin; Limits: Meta-analysis, systematic reviews, Randomized controlled trialsSearch: myofascial painSearch: TMDSearch: botox
Comments on
The Evidence
The studies shown represent a strong level of evidence. Each randomized controlled trial has a small sample size; so, in order to obtain more conclusive results, a larger sample would be ideal.
Applicability These articles are applicable to the patient group in question. Many patients report to the dental clinic with myofascial pain and other disorders related to TMD. Even after self-management therapies or occlusal splint fabrication are prescribed, pain is not always relieved due to low compliance.
Specialty/Discipline (Public Health) (Oral Medicine/Pathology/Radiology) (General Dentistry) (Oral Surgery) (Orthodontics) (Restorative Dentistry)
Keywords Botulinum toxin, botox, TMD, myofascial pain
ID# 894
Date of submission: 07/07/2011spacer
E-mail williamser@livemail.uthscsa.edu
Author Erica Williams
Co-author(s) e-mail
Faculty mentor/Co-author Erica Oliveira, DDS, MPH
Faculty mentor/Co-author e-mail OLIVEIRAE@uthscsa.edu
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)
post a rationale
None available
Comments and Evidence-Based Updates on the CAT
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by Catherine Tatum, Nikhil Reddy (San Antonio, Texas) on 10/03/2014
A PubMed search on botulinum toxin treatment for Myofascial Pain Syndrome was performed Sept 2014. A more recent publication was found: Soares 2014, PubMed: 25062018. This Cochrane Database Systematic Review included 4 studies with a total of 233 participants showed that the evidence is inconclusive for the use of botulinum toxin for the treatment of MPS. Further investigation into this subject is needed before its effectiveness and safety can be evaluated.

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