Case #2

By: Sonali Demla, DDS

A 70-year-old female presented to the OU Advanced Education in General Dentistry program with the chief complaint of, “The right side of my jaw hurts. I constantly clench and grind my teeth.” The patient reports no relief from wearing her nightguard, and states she consistently has migraine headaches. The patient has a medical history significant for rheumatoid arthritis and osteoporosis. The patient’s dental history includes 4-month hygiene recalls for localized periodontitis and multiple fixed restorations. Clinical findings showed that the patient presents with a square-shaped jawline, making her face appear fuller and more masculine at the angle of mandible bilaterally (Figure 1). She also presents with significant right masseter hypertrophy.

Many treatment options exist for patients that present with TMJ pain due to clenching/bruxism. These include bite splints, mouthguards, jaw exercises, and in some cases, surgery. However, many of these treatment options are difficult due to poor patient acceptance and compliance. Botulinum toxin (Botox) therapy was presented to the patient as an alternative method of treatment and accepted. While known for its cosmetic uses, botulinum toxin can also be used in various aspects of dentistry including TMJ pain due to clenching, and gummy smiles due to excessive lip retraction. The use of botulinum toxin in the masseter muscles imposes muscular relaxation and atrophy, allowing the patient to reduce damage to their dentition. The muscular atrophy of the masseters may also result in facial slimming. Results generally last between 3-4 months, and a minimum of 3-4 treatments are needed for the full benefit. However, when botox therapy is curtailed, relapse is not uncommon.

After thorough analysis and planning, this patient’s treatment entailed a sequence of four injections to the left masseter and four injections to the right masseter for a total of 20 units of botulinum toxin per side. For patients presenting with chronic bruxism, the average amount of units delivered per side is between twenty and thirty. It is recommended patients begin with 20 units and determine if more units are needed, as it takes 7-10 days for the dose to take effect, with maximal effect not being reached for roughly 3 weeks.

ELEMEK, E. (2022). Retrospective Analysis of Geriatric Patients Treated with Dental Implants and Implant-Retained Prostheses. Turkish Journal of Geriatrics / Türk Geriatri Dergisi, 25(4), 559–567. https://doi.org/10.31086/tjgeri.2022.314

About The Author

Dr. Junior Cruz was born and raised in Dallas, Texas. He attended the University of Texas at Dallas where he graduated with a Bachelor of Science degree in Biological Sciences with a Biomedical Sciences Certificate. He received his Doctor of Dental Surgery degree at Texas A&M College of Dentistry with an Education for Healthcare Professionals certificate in 2022. After completing the AEGD residency at OU College of Dentistry, he plans to practice in Oklahoma City, OK.

Patients may discover that their bruxism has reduced, however, their migraines persist. If that is the case, botulinum toxin may be administered adjunctively into the temporalis muscles for improved effect.

The masseter muscle has a quadrangular shape and botox must be administered into the muscle belly for optimal effect. The superior border of the area of administration into the muscle belly was noted by a line between the commissure of the lip and the tragus. The inferior border was noted by the inferior border of the angle and body of the mandible. The anterior and posterior borders of the muscle belly were mapped by having the patient clench and release several times to be able to clinically detect the patient’s masseter muscle. An alcohol prep pad was used to effectively sanitize the skin prior to injection. Four dots were then marked on the patient’s face in the shape of a diamond to represent the sites of administration (Figure 2 and 3). Five units were injected into each location for a total of 20 units bilaterally. The patient was scheduled for a two week follow-up appointment.

The patient states she has had great relief, and she looks forward to incorporating her botox recalls with her hygiene recalls. This experience was educational and rewarding to see that dentists can change patient’s lives in many other ways than just the appearance of teeth.

About The Author

Dr. Sonali Demla is originally from Lawton, Oklahoma. She attended the University of Oklahoma where she graduated with a Bachelor of Science degree in Chemical Biosciences with a minor in Business. She received her doctorate at the University of Tennessee College of Dentistry in 2022, and recently completed the AEGD residency at the OU College of Dentistry. Dr. Demla plans on practicing in the state of Texas.