Botox for TMD – Indications and Protocols – PDP123

Jaz’s Introduction:
So, that things like occlusion, orthodontics and temporomandibular disorders. Today, I’ve got none other than, Dr. Sheila Li on the show, who really is the best person to discuss the USE OF BOTOX OR TOXIN for the management of TMD. I’ve actually wanted to get into this field. But for those who watch the videos on YouTube, does this look like the face of someone who is interested in facial aesthetics? I really didn’t want to learn lips and eyebrows to get to the really important stuff like the masseters. But, Sheila is great at both of those things. And teachers dentists like me who are more interested in the functional aspects like TMD and gummy smiles. So, by the end of this episode, you will know which diagnoses, symptoms or patient features lend themselves to Botox. Now, this is really important because on the dental groups, I see Botox suggested in the word bandied all the time, all over saying, ‘Yeah refer for Botox or you can treat this Botox.’ But really, not all TMD lend themselves to the management of Botox. Now, BOTOX CAN HELP for TEMPOROMANDIBULAR PAIN, but you’re not going to treat clicking and locking joints with Botox. You have to get your diagnosis right. We also discuss what regulatory requirements there are for dentists who only want to do Botox for the TMJ pain. And the answer might pleasantly surprise you. And finally, we DISCUSS THE PROTOCOL. How many visits? How often? Is it something you have to do for the rest of your life? Where does occlusal appliance therapy come into it? Don’t worry! Me and Sheila have got you covered.

The Protrusive Dental Pearl:
The Protrusive Dental Pearl for this episode is related to the MUSCLES OF MASTICATION. Do you routinely check the masseters and temporalis at your new patient examination? If so, what are you actually checking for? As a restorative dentist, the most important thing I want to know that will influence which materials I use, and the occlusal risk for my patients is the SIZE of the MASSETER. You see, large masseters and temporalis muscles, and the history of destruction and mechanical failure are features that I take very seriously when treatment planning. On the flipside, someone with very weak muscles usually poses a much less of a parafunctional risk. And I’m more likely not to worry about lengthening their incisors, for example. So, if you want to learn more, join the Facebook group, Protrusive Dental Community, because I’ll be doing a little blog post on there about the significance of masseter, temporalis, their size, and share some photos of patients with meaty masseters. And how, in those individuals, is correlated with a higher occlusal risk and more destruction of their teeth.

Main Episode
Now, let’s join the main interview with Dr. Sheila Li. Sheila and you and my old friend. How are you? Welcome to the podcast.

[Sheila]
Hi, Jaz! I’m really, really well. Thank you so much for having me. It’s really exciting to be here. And I’m really glad that I’m doing this with you today.

[Jaz]
Sheila, I see all the BSPD, all the events and stuff, this was like nine years ago. We qualified roughly similar time. And then, you know, we went our different ways in our careers. And it’s amazing to see what you’ve achieved in the space you’re in and facial aesthetics. And I love what you’re doing. So, for those who haven’t heard of you, Sheila, tell us about what you do at the moment? But then I might just take it back a few pegs and tell us about your journey into facial aesthetics.

But specifically, for today’s podcast, what I really want to know from you Sheila is, why is it that you, as someone who is doing wonderful things in the field of facial aesthetics, you decided that, ‘You know what, I actually want to now also use this to manage people in pain.’ Because I imagine that it can be easy when you go into facial aesthetics to be like, ‘Oh you know what, I’m happy to make people look pretty, but then I don’t want to touch this stuff because pain is complex, pain is difficult.’ You know, you’re in a difficult niche if you’re helping these people out, right? It’s so rewarding, but I want to hear it from you, how you got into that. Was it an accident? Or was this planned?

[Sheila]
Oh! What a great question. So, as you may know, dentistry wasn’t my first degree. But even before I graduated, I knew that I wanted to be the very best dentist I could be. I was also inspired by my best friend. She was a doctor training to do getting her BDS so that she could go and do max Vax. She was actually the one who trained me in aesthetic medicine. And following on from this, I focused a lot of my energy on investing in courses, and increasing my injectable case numbers early on in my dental degree. So, quite quickly, after I graduated, I absolutely loved that I was able to offer aesthetics alongside dentistry as a complete sort of option for my patients. But, I really lacked confidence in my abilities. And I wanted to do aesthetic medicine, as well as dentistry because of the joy that I knew I could bring to my patients in improving their confidence, right?

You mentioned the sort of wrinkle treatments and the facial treatments that I do. That helps improve their confidence. Because we know as dentists, we can improve their confidence with their smile. It’s one of the most important features of the face. It was early on in my career and I had so many dentists and so many colleagues telling me that I needed to concentrate on my dentistry. That I should get good at basic dentistry before branching out to do anything else. And that actually, I should be doing both things at once. And I was like, ‘Why? Why can’t I do both?’ Who says, I can’t do both? I do really, really well, you know, so I wanted to challenge that. And that’s what I did. I spent the first few years of my career investing everything that I had and then reinvesting everything that I made in my training.

[Jaz]
Can I just pause you Sheila? For those who don’t know, like, I’ve seen some of your work, you’re supposed to, like ‘For dentists, By dentists’, you know. For those who don’t know, Sheila is actually a really competent, really good restorative dentist. So, it’s hats off to you for then deciding that, “Okay, I’m gonna go further into special surgeries.” But, you know, it’s not like you were a below-average dentist. We focus on photos that you are very competent restorative dentist.

[Sheila]
I am, I really am. And, you know, because pretty much I invested everything that I had. All of my time, all of my energy, both in facial aesthetics and dentistry, I did it both. And I demonstrated that. It is possible to do both really well. You just have to be able to provide that treatment to the highest standard, both in facial aesthetics and in dentistry. It’s absolutely possible and it can be done. But it takes time, it takes commitment; it takes an investment, and it takes energy. And all of this is so much easier when you have someone in your corner supporting you and guiding you.

And that’s one of the lessons that I’ve learned. I’ve learned that the hard way, and it took me years. But, you know, when someone’s able to show you how they’ve done something, it just takes so much time off of your plate. And that’s the reason. For the last eight years, I’ve taught and I’ve worked in seven different places, every single week. I’ve learned from lots of clinicians. Sometimes I worked, I didn’t earn anything. I went in just to shadow people and work as a nurse for clinicians. And that really allowed me- Yeah!

[Jaz]
That’s the way it should be.

[Sheila]
Yeah, absolutely. It’s the best way to learn, actually; it’s the best way to kind of get experience from much more experienced clinicians. And that’s how I significantly improved my skills, personally. Both from cosmetic dentistry and facial aesthetics.

[Jaz]
Just sidetracking a little bit, Sheila, on that. Because you’re mentioning all the things that you did extra, that you know, where you weren’t being remunerated at the time for it, that was to gain experience. I wonder if this has also affected you. A common issue I find with our colleagues is that they want to up their game in a certain discipline of dentistry. And then the stumbling block they approach is that they now need to ask their principal for certain equipment, X, Y, Z, whatever. And then they’re like, ‘Well, no, not really, because it’s not gonna work as part of their business plan.’ And then that’s it! They know that the journey ends for that associate or whatever. So, did you have to go through the struggles of, you know what? I have to buy my own toxin. I have to buy my own facial aesthetic stuff. I have to buy my own, like, you know, clamps, whatever, you name it. Do you also have to have that struggle?

[Sheila]
I did. I bought my own soflex discs, because there were certain ones that I wanted to use. And they were too expensive. You know, I bought certain instruments for composites that, again, they were far too expensive. And actually, we were worried about things scratching. But you do these things. Because actually, it’s too short-sighted to see that it should be an investment for the principal. And actually, it’s really, really nice if they will buy those things for you. But if they don’t, they shouldn’t be the things that stop me from doing it. You’ve invested your time, your effort, your energy into going into these courses, and you need these tools. And without them you can’t do that. So, it isn’t a case of going on the course and then forgetting. But also what I find really important is, that post course support, which you do really, really well, Jaz. Like having that person, a cold your liberal accountable, be there and support you and say, you know, perhaps you probably should take that next step. Are you seeing enough cases?

Because one part of it lies in the fact that you cannot, you know, not having the instruments or not paying for the more expensive composites. The other lies in the fact that, too many associates expect their principals to find all the patients for them. And it doesn’t rely on anesthetics. And sometimes you do have to do a little bit of the way that you approach your communication skills with your patients. It’s not just the clinical skills. It’s the soft skills that we have to work on the way that we talk to our patients. Our communication and how we talk and approach treatments and treatment planning for the patients, as well. You know, your principal can get a patient through the door, but the rest is then up to you as the treating clinician. So, it’s all of those things and all of those things, they come together beautifully, to be able to allow you to practice dentistry to a really high standard. Once you’ve done enough of the learning and the practicing. It’s just doing and seeing cases-

[Jaz]
And seeing the cases consistently enough to actually build your skills. And you made a good point there that you know, what people expect their principles, get the patients. Let’s say you want to go into facial aesthetics, for example, and no one in your practice has ever before offered this. So, you have to expect that already in the marketing of your practice, the marketing or website, there’s zero stuff on this, right? So, you now, as the associate perhaps, or the Brit, or the principal has acquired a practice or whatever, have to do some extra work to market to the world, and to change the way that a practice communicate so well that, Hey, we’d love to help you with this problem, right?

[Sheila]
Yeah, absolutely! And this is what I tell my mentees all the time. Lots of dentists will tell you. They’ve been on a course and it means, this doesn’t necessarily lie just in facial aesthetic. They may have gone on, for example, a laser gun contouring course, or whatever it is that they’ve done, you know. And they haven’t put to use what they’ve been taught. And they’ve learned because they can’t find the patients. And they expect the principals to find patients, and a lot of principles are not even familiar with the field.

So, you have to also do a lot of the work here. You know, social media is such a massive factor within all of these. Patients are using social media as a way to inspiration, as it were. And a lot of patients come from social media, hate social media. It’s not enjoyable; it’s spoilsport. You have to do it! You absolutely have to do it. You have to do it, because it’s also social proof. Patients want to see that you exist. That you’re real, that they can relate to you. And actually you’re just yourself. And it’s not hard work first and foremost, and actually-

[Jaz]
Show your human side.

[Sheila]
Yes, absolutely! Show your human side. And then you attract similar patients that are like you as well. Which are the easiest patients to treat, by the way, because you can have normal conversations with them. So, there is a lot of legwork to be done, and there were associates that will be or the dentists that will be successful. And they are the ones that kind of take the initiative, and they go, and they do that. And so, I did do that, as I said. But by doing all of those, I was able to improve my skills significantly and the confidence that I gained. And it’s that confidence that you know, when you tell your patients that you can get that this is what your treatment plan for them, and you can deliver on those results. You know, that’s when you’re able to do it.

[Jaz]
They can smell it.

[Sheila]
Yeah! And you’re not talking them out of treatment, because that’s often what we do. We learn a skill and then we start talking about treatment, because we’re not too sure about whether we can actually deliver on that. And that’s what happens. I think, I believe in dentistry as well. So, you know, it’s something you have to invest in. And for me specifically with facial aesthetics, something I had to invest in outside of dentistry, and then, you know, work away from the dental practice so that I could then bring it back into dentistry. But, you know, don’t get me wrong. I absolutely love dentistry, and I love facial aesthetics. But I did come to a bit of a crossroad after I became a parent and maintaining that momentum that I had and the successes. I built pre-motherhood was completely doable. But after my children came along, oh my god, it took its toll. And I had to make a really difficult choice. And I chose to step away from more traditional dentistry and that’s sort of, you know, that’s how I’ve come to do facial aesthetics.

[Jaz]
Niching is a beautiful thing to do in dentistry. It is such a wonderful thing. And, you know, mom is the hardest job in the world. So, hats off to all the moms out there. Working hard and achieving their dreams and aspirations and stuff and doing that kind of stuff. Why is it that you went into also helping your patients with myalgia and myofascial TMD or TMD of muscular origin? Wouldn’t have been really easy to just take a back seat and say, ‘You know what, I like all the aesthetics stuff.’

[Sheila]
Yeah.

[Jaz]
What actually inspired you to think actually, I want to help people in pain as well?

[Sheila]
So, you know, you’re right. I still consider myself to be a dentist and I’m still part of the dental team. Yes, I do the more facial aesthetics, cosmetic side. I get to make patients look great. But, I also get to work alongside my dental team to improve the functional muscular elements within the mouth as we’re going to discuss managing TMD and providing an alternative option to treating a TMD pain, and migraines, managing bruxism, all of those things. And the joy that you get when you really get your patient out of pain. One of the things that we can potentially do right to make patients feel better. When you take a patient out of pain, and we know with TMD patients, often if they’re lucky enough to see the right person, if they’ve gone through a couple of phases of different types of splints, different types of treatments, they’ve done, you know, by time if they’ve come to you and they’ve done all that they’re already really difficult.

They don’t even believe in the whole system as it is. But when you actually get the diagnosis correct, you can treat them and get them out of pain. It’s a feeling that you can’t replace by doing cosmetics. You can’t get that from anywhere else. I actually realized that, there’s not enough dentists doing this as part of the armamentarium that we’re offering patients. And I believe that dentists can do this. And they are able to do this really, really well. Because, you know, we inject local anesthetics everyday. It’s no different. It’s just learning the anatomy and understanding what your goals and what your aims are.

So, I do believe that dentists should be the people that the conditions are off officially stated. But, particularly functional. There’s no reason why we every single dentist can’t. And that’s my goal. That’s my reason for sort of branching now more towards training and mentoring only dentists, especially to deliver this part of functional facial aesthetics, using neutralizing toxins to do that really, really well. And supporting them to do that case planning and holding them sort of accountable. But doing it as part of an overall care plan for the patient, not in isolation, not by itself. As part of the full plan.

[Jaz]
I agree that there are some dentists out there, like myself, who have zero interest in facial aesthetics. However, I have a lot of interest in functional restorative and managing TMD, which is a lot of what I do. And therefore, when I attended one of your webinars, you talked about two really great uses of Botox or Toxin, or watch aluminum toxin if you want to call it. For the restorative dentist who, just like me, is interested in managing TMD was for Botox and also for the gummy smiles. And that was really great. I want to ask you specifically to focus more on the masseters and temporalis. Botox today mostly master slave, if you focus on one topic.

[Sheila]
Yeah.

[Jaz]
What is your ideal case selection? So, you know, that the patients come in for a consultation with you regarding the TMD. What are the signs that a patient will tell you that, ‘Okay, I’m gonna get a good result here with Botox,’ what are the signs that are suggesting that perhaps this isn’t the right case for Botox? This gonna help the dentist listening to know A) if they don’t already provide his current treatment. At what point can Botox help their patient? But, also whether they feel as if, ‘Oh, actually I see these patients every week, and I could potentially help these patients.’ So please let us know about case selection.

[Sheila]
So, your patient’s symptoms, and what you can assess and see and feel with the patient will lead you to your diagnosis. And we know that TMD is one of the most common causes of chronic facial pain for the patient when it’s not related to, you know, the dentition itself. And we know that the etiology is multifactorial, and we don’t know why exactly, some patients experience this pain and others don’t. And why some of these patients actually just get to have TMD. But generally, TMD is classified into two different groups. We’ve got the articular and the muscular origin. And often both of these are present together. And it’s the muscular origin that we need to treat when it comes to Botox. So, that diagnosis is really important.

So, patients will obviously usually present with facial pain. And this is often the reason why any patient will come seeking treatment, particularly from a dentist as well. And pain, particularly in the masseter and maybe the temporalis muscle, so they may complain of things like headache, or morning headache or headache at the end of the day, are the most common symptoms that I see. And that patients will complain as well. And often what you’ll find is when you’re doing your extra oral exam, when you’re palpating the masseter, they might say, Oh, there’s a bit uncomfortable, or actually I do get jaw pain. What I find is it’s usually pain on palpation, they’ll already complain a pain. They can pinpoint where the pain is for you. And then when you palpate the masseter, it will usually be uncomfortable for them. There’ll be have some pain on opening and this may spread beyond the area as well. They also may have headaches. They may complain of headaches, and they may have pain around the ear area. This could be close to the TMJ or within the TMJ joint itself.

This is where I push and refer over because TMJ joint pain is more arthralgia and Botox here will not do anything. But of course, you may get the patient’s pain off anterior to the to the ear. In this case, we’re still looking at the superior portion of the masseter because it originates on the zygoma, which literally runs in line with your ear there. And treating the masseter for these patients will help improve significantly their discomfort and pain in the area. We also know, as I mentioned already, that in a lot of cases there’s a combination. So, as long as we can identify a muscular component, then absolutely, I would approach with Botox alongside prescribing a splint for the patient. I also find what’s really useful is there’s a screening tool, 3Q/TMD. It’s really useful at identifying the myalgia patients, which essentially looks at pain in temples, the jaw and the face. But it is really useful for dentists who don’t manage TMD and bruxism to aid their decision to obviously refer to colleagues who do. And so, when patients do have pain in any of the muscular areas, usually the masseter, the biggest muscle of mastication.

So, that’s usually where it starts. If they have some additional headache pain, then I may treat them there, but often it’s the masseter first before anything else. And I find Botox to be a really useful adjunct to splint therapy, obviously, in conservative management, as it gives the patient a little break. And it does significantly improve their pain. We know patients aren’t religious in wearing their splints. I’d love them to be, but they’re not. Their compliance tends to be poor, especially when it starts to get a little bit better as well, right? So, they’re wearing and it gets a little better, and when it’s not wearing, it gets bad again.

[Jaz]
I’ve got videos after video consultations or video testimonials on my patients saying, ‘Oh, it feels great.’ And I see them six months later. ‘Oh, I felt so great. I stopped wearing it. And then the pain came again. And I wore it again.’ I got that on video from multiple patients. So, patients do get a little bit cocky. They get a bit complacent. And so yes, that’s another avenue to go by, which is really fascinating, actually. The thing I want to really emphasize here, and it’s a great point you made, is that, ‘Guys, when we’re referring on for patients who you think may be a good candidate for Botox. If someone’s main issue is clicking, locking, and very precise pain, exactly where the condyle-disc assembly is. That’s an intracapsular patient, okay? That’s not the kind that’s going to benefit from Botox. There are other things we need to do for that patient. The kind who is like diffuse pain all over. They’re kind of point everywhere. I’m in pain everywhere. That’s more the one that lends themselves to having Botox. So, that’s the main sort of takeaway there.

Now, you mentioned about being an adjunct to splint therapy and whatnot. In which order do you go like, do you just post because we are allowed to disagree. I think the best episodes are when my guests and I disagree, it’s completely cool. But where do you see that in the hierarchy? I get a lot of patients who come to me and they say, ‘Should I have Botox first?’ Then I screen them. Okay. Yeah, it’s not intracapsular. It’s muscular. Can they benefit from Botox? Yes. But then we have that discussion: ‘Do you have an appliance? No, you don’t. Okay, well, maybe we should consider that as well or maybe even first.’ But because they’re coming to seek you, as the facial aesthetic practitioner, and they already value. And if they’ve sat in your chair, they’ve already done a bit of research, they value that this is going to help them. And therefore, that’s a huge part in them getting help from it. So, do you ever give Botox as a standalone, and then maybe just encourage the splint? How does it work for you?

[Sheila]
So, first of all, it depends where I’m based. So obviously, if I’m working in dental practice, for me, it can be done alongside the two. If they’re in severe acute pain, then I may make them an NTI immediately, because that will help. And I know that I can inject them with Botox, and within two to three days time it will already started to work. If they’re in my chair, because they’ve come to see me, I will always do the Botox first, because I know in two to three days, it will work. But the next thing that the patient needs to do is either see a member of the team for the full assessment, and I’m prescribing with a splint. We know that, of course, we’ve got to take the impressions and that’s going to get sent off to the lab. So, it’s gonna take time. It’s gonna take up to two weeks.

And as busy as we are at the moment, so it can take longer for that to come back. In the meantime, they’re still going to be in pain. So, the Botox can start getting to work whilst you start doing your splint stuff. So, if I’m fortunate enough to be in a dental practice, it’s both they will see me and they will see either a member of a team straight after or send them out to the dentist, and have that. If they’ve already had the splint made, then they can still see me afterwards. Because remember, the toxin also helps to reduce that daytime clenching as well, because they’re not going to be wearing this splint during the daytime. So, that’s where it can be used. And if they see me, I’m putting it in straight away because I know that it will start to work into three days time. And actually, they can then go and get their impressions and the next stage of their plan. But absolutely, it’s done as an adjunct.

The only time where I will not talk about a splint is if they’re coming in for cosmetic reasons where we’re trying to slim down their jaw. My primary aim is to preserve and protect the teeth. And if they have TMD, if they have bruxism, we know that this can lead to tooth wear, tooth fracture and worsening the pain later on as well, and maybe potentially causing a joint problem. So, it’s always prevention. And Botox alone is only temporary. Maybe patients can afford to have it forever, but most cannot. So, the splint is what’s going to ride them through it and how to protect them. So, we need to be sensible about this. We can’t just be saying, ‘Right, Botox is the answer for everything’, because it isn’t.

[Jaz]
And since you mentioned, let’s say we have a patient, I made a splint on them. I said, ‘You know what, you got huge masseters, as well as a splint.’ I want you to see Sheila, the patient that comes to you, you’re gonna do your thing and get their Botox, hopefully smaller and working in not such a hypertrophic way, maybe temporalis as well. Now, what do you say to that patient in terms of frequency of Botox need for the immediate sort of year ahead? And also lifetime? What is the kind of discussion that you have?

[Sheila]
So, that’s, again, a really, really good question and important question for patients because you have to manage the patient’s expectations. And my plan for patients is they need to be seeing me for the next year. If they don’t intend to do that, I just don’t start the treatment because it’s not effective. There’s no point in having one or two treatments, because they’re unlikely to see the long-term benefits. So, it’s three treatments exactly three months apart. No break. Maybe a fourth treatment at month nine. Sometimes, depending on how hypertrophic they are, how much pain they’re in, and how much reduction or atrophy we get from the first treatment, that will determine whether they need a fourth treatment, or whether we space that sort of three appointments in a year or four appointments.

After this point, if they follow the plan, there will be a significant reduction in the masseter bulk. And then, maintenance is once every six to nine months, because all you’re doing is stopping. It’s not taking them six to nine months to get to that level. They’ve taken the time patient presents. They’re around in their mid 30s, right? Work is getting more intense, lifestyles changing; maybe they’re starting a family. Things are getting more sort of a psychosocial element of TMD that we’re treating. So then, once we’ve reduced the master bulk to where we want it to be, the maintenance is every six to nine months or once a year. And if that is the case, and they’re wanting to do even less than that, they absolutely need to be using their splints. So, that’s what I said. And they also need to know, it’s so important that the patient needs to know that it doesn’t kick in for at least a few days. And there may be some balancing that we may need to do around about two to six weeks. Also, depending on the bulk of their muscles and level of pain, I may do an additional dose at six weeks the first time we do it.

Because we know that the muscle starts to recover from the Botox at six weeks. And if I think I don’t even want it to quit, I’m gonna go in and literally just whack another dose in there. That’s what I do. But we know that Botox is safe and it’s effective. And so, we can do that, but we don’t make a habit of doing that. Because we don’t want you to become resistant to the Botox, because then that’s a nightmare, and we’re not going to be able to treat them.

[Jaz]
Brilliant! I think that’s a good common question you probably get in terms of frequency. And I didn’t know that, you know, they can taper down to about up to an annual that’s really good to know. What about those patients? This is something that, you know, I’m very much coming to you as the expert here. I have some patients who have got myofascial pain, myalgia, but they don’t really have the hypertrophy element. You know, you don’t always need to have hypertrophy for them to have facial pain. Their muscles are in the normal ranges. Would that patient still benefit from having Botox that you feel their muscles, they’re not particularly large, but they got a clear diagnosis of myofascial pain, maybe got referral patterns, their teeth, and whatnot. So, we’re kind of sure about a diagnosis, do you think there’s a place in treating that patient? Is that patient more difficult to treat?

[Sheila]
There is definitely still a place to treat them because again, it’s that spasm of the muscle that now you’re referring to and it’s the overuse. Maybe it’s early on. So, what normally happens is, at the beginning, when they’re starting to overuse the masseter and the muscle spasms, they’re getting that pain, but they’re not necessarily getting the hypertrophy. It’s that repeated clenching that then grows the muscle, kind of like being in a gym. It hurts more in the beginning when you’re first lifting weights. But as you progress, it’s not as painful, but the muscles are really, really tight, aren’t they?

So, it’s exactly the same way. You will know when you can palpate the masseter and you can feel it. And I encourage you to do this if you have masseter pain. And you can almost feel the knot, you know, that sort of same sensation after we’ve had a hard day at work and we’ve got really bad shoulder pain. We go and see a sports rehab and they literally dig in; they find a knot and they just really reduce it. You don’t necessarily have to have bulky muscles. But if you find that knot to that spasm, you can still-

[Jaz]
Sometimes as a maxfax surgeon described it as once.

[Sheila]
Yes! You can feel it. You literally can roll over with your phone. And, you know, because as soon as you press in, they almost like just sort of move right into your finger. And if they’re so comfortable, and they’re like ‘Oh, that feels so good.’ Okay, I know that if I can specifically just put a little bit of Botox here, allow them to rest and relax. Now the alternative to this is that they go see a physiotherapist where we can get some stretches from relaxing. They can do some jaw exercises. So yes, we can still put Botox. It still has a role that has an improvement. But the dosing that I would use in these patients will be less. And actually, they wouldn’t be as a bigger long-term plan. They would be more about education.

Potentially getting them to see physiotherapy, getting them to massage and jaw exercise themselves. And actually, putting them down the route of some therapy, because then that’s going to protect them and hopefully help prevent that need for heartburn. That needs a long-term sustained treatment plan. And this is where we may just do a spot treatment of Botox to help relax and give them a little bit of a break and reducing that muscle spasm. So yeah, it’s still effective. But it’s not the only answer here. There are other things that we can do. And actually, the patient has rested their jaw, as well. Gave them a little bit of ice to rest their jaw, do some jaw exercises. You probably find that actually fine. Because it goes away, doesn’t it?

[Jaz]
It does! And most patients need a team approach. You know, they need the education, the appliance, the whole conservative care therapy. Physiotherapy helps greatly. For some people, there’s a posture element. They need the chiro. So, that’s when it gets more and more complex. And when we get chronic pain, pain that’s been there for more than three to six months, yet chronicity. And those patients become much more challenging. So, at that point, yes, they may then be seeing multiple people. But that’s sometimes, what’s needed. When it’s early on, we want to get in there and treat them and help them prevent from entering the realm of chronic pain. I want to ask you next, with general dentists who then decide to do facial aesthetics. I can see that, ‘Okay, you need to get some additional indemnity.’ I want you to tell me about what’s involved in that. And is that true that it’s an additional indemnity to get? But also, imagine I do some training with yourself. For example, I learned how to place Botox into a masseter and do some lip repositioning. Would I get specific indemnity that covers me for just the functional elements? Does that exist? Because I can see that as being a really helpful thing if it exists.

[Sheila]
Let’s talk about that first. Let’s talk about general facial aesthetics. Yes, you will need completely separate insurance to do facial aesthetics, if that’s what you’re doing. But for dentists, who are just interested in treating the functional problems and treating the disease, diagnosing TMD and sort of hyperactive lip muscle repositioning. You know, as dentists, we’re able to assess a diagnosis, and if we are appropriately trained, we can treat them so there is no regulatory requirement. Dentists just need to be appropriately trained and indemnified. That’s the GDC expectation.

Your dental indemnity will ensure you treat TMD, bruxism and gummy smiles. Because they do anyways, if you want to do some Crown Lengthening, you’d be able to go back to your dental indemnity. It’s the same here; we’re not cosmetically treating these patients, in a sense. We are diagnosing the condition and treating it as a disease. And so, you’re absolutely fine. You don’t actually need separate insurance. You just need to let your indemnity know that you’re adding these treatments to your plan. There shouldn’t be any issues because you’re doing it from a dental perspective. You’re not doing it as a Botox-

[Jaz]
If I throw a curveball your way though Shiela, I’m gonna throw a curveball. So, I made something that I didn’t know that actually was amazing. So, if I want to do Botox, it’s I’m treating it purely for functional reasons. That’s dentistry. So, that’s how I manage my TMD anyway. But then, what you shouldn’t do if you’re that dentist now, is start to see these patients for whom you haven’t made a diagnosis of myalgia and myofascial pain, but they just have big masseters and now you’re treating large masseters for a cosmetic reason. That’s where it’s a blurred line and you shouldn’t probably cross that. I imagine, right?

[Sheila]
No, you shouldn’t. In which case you do need cosmetic indemnity for that, and actually still, you can just have that added on to your insurance more than likely. Just speak to your insurance company, and they will indemnify you, but you have to be specific about what you’re treating. And absolutely, you have to make, if it’s a diagnosis, that’s what you’re treating. You can’t be treating for cosmetic reasons if there is, that’s a real blurred line, so you’re right. Yes, you do need to get advice and speak to them and they will show you. Generally, the major indemnity companies will insure you for simple Botox treatments anyways.

[Jaz]
Okay, brilliant! It’s another common question that I know people want to know.

[Sheila]
I want you to just jump back on that, though. The thing that we need to be careful as dentists as well is that a lot of dentists are unfamiliar with advertising prescription medicines. So, Botox is a prescription-only medicine. We cannot advertise or market prescription-only medicines. We cannot use the name, we cannot advertise it. And I do find that many dentists fall short of this, first of all, because we call it Botox. That’s a drug and on their websites. They will use words like Botox treatments for TMD and even on their windows-

[Jaz]
Botox is the brand name, right?

[Sheila]
Yeah.

[Jaz]
So, even this podcast episode, we should rename it botulinum toxin and not Botox, right?

[Sheila]
Yeah, we should. But we can’t even say botulinum toxin, because again, it’s all prescription medicine. So, you can talk about bruxism and TMD, but you can’t talk about Botox. And it’s important that we understand that it’s a prescription medicine, so we can’t just advertise these services on our websites and things. It’s really important.

[Jaz]
So, how does one do it? Like, I know people do wrinkle relaxing when it comes to-

[Sheila]
Can’t do that. They can’t.

[Jaz]
Really? I didn’t know that. I see that all the time. Okay, wow! So, how do you do it for functional and facial aesthetics but functional?

[Sheila]
So, for a functional perspective, we just talked about TMD. How we can manage TMD as a dentist. How we can, you know, what’s really important is the assessment, the consultation and the treatment plan and being looked after. And you can talk about the different types of options that can be used. But it’s all surrounding the consultation with regards to things like anti-wrinkle, unless you’re offering other anti-wrinkle treatments that aren’t prescription medicine. If basically you’re trying to get around using the word Botox, you can’t do that. You just can’t. Just because lots of people do it doesn’t mean it’s right. You’re not allowed to do that and actually-

[Jaz]
Wrinkle relaxing, is that a big no, no as well? Because I’m thinking of all my friends practices who have that on their front door?

[Sheila]
Nope, because that’s obviously Botox, and you can’t, on social media posts as well. You can’t hashtag Botox, hashtag Botox injections, or anything like that. You cannot use any of those terms whatsoever. You just have to talk about the toxin and you just have to talk about the consultation.

[Jaz]
Just for the legal purposes, those listening. This is an educational episode. This is not for patients. This is a discussion between two professionals about the use of this toxin. Now, what percentage is an interesting one? My success rates in managing TMD, let’s talk about that actually, they’re not 100%. No one can ever expect that from a pain-oriented condition. I would say that, in my general population of patients, ie my own general patients who I see. I pick up the signs of TMD. But not necessarily the symptoms. I pick up the signs. I’ve got an extremely high success rate of them coming back and saying, ‘Whoa, I feel better.’ And I’m like, ‘Whoa! like I never knew I was doing so bad. And my headaches. My migraines I had 15 years ago.’ I got videos after videos.

But those patients who seek me out, who’ve been suffering with signs, come first. Then the symptoms come. So, now they’ve gone beyond the signs, they’ve had the symptoms, and they’ve been suffering for months. See multiple specialist and now they come see me. My success rates will be much lower. They’re in the 78% percent, which is pretty much like, it isn’t literature. So, what has been your success and any trends that you’ve noticed in terms of Botox, or this toxin, that I won’t say it any more toxic, unhealthy?

[Sheila]
Okay. So, you know, when it comes to success, what’s really important is getting the diagnosis, right, isn’t it? If that’s the most important thing. And of course, in my patients, who where myalgia is the muscular component of TMD, they experience the best transformative results, because they’re usually the ones who tell me that I’ve changed their lives and had the biggest impact on their lives. And that’s fantastic! And that’s where you’re going to get the best results. Where there is also a joint sort of alder component, then patients can expect a significant reduction in pain, but not a complete improvement in their symptoms. But it’s understanding that these may coexist and understanding actually, that you’re managing the pain. You’re not claiming to try and cure them of pain and make them pain free. And therefore, managing their expectations.

This is a reason why, I would say, that when it comes to muscular components, even if it’s in addition to a larger, all I’m ever saying to the patient is that, this will help to improve your symptoms and reduce your pain, you may start to have longer periods where you’re painful. You may not have headaches and wake up with jaw pain. But it’s unlikely that this will completely correct all the pain altogether; then my success rate is just there every single time. Because I’m acknowledging the fact that my goal isn’t to completely cure them of their pain and make them pain free. Therefore, I’m never promising that I’m always just promising an improvement and that’s the key and that’s the reality. Now, talking about the difficult patients who have gone see multiple people and you know, they’re not just getting, because I get the referrals as well. Because as I do more and more of this, I’m getting more referrals from the trickier patients. So these patients, you’ll know they’ll come in, and the pain is generalized. It’s not just on their face, it’s on their neck, they’re suffering from migraines, because, of course, we’ve used toxin-

[Jaz]
They’ll also have depression, fibromyalgia, all the other things. It’s very complex, chronic pain patients.

[Sheila]
Yes, absolutely! And that’s it. And in those patients, again, you may be able to improve their symptoms. But because they’re suffering from all other problems, they’re taking painkillers, left, right and center. There on, you know, muscle relaxants, antidepressants in those patients, much less success rate. And, but I already expect this, and I know this, and I always say to them, ‘Look, we can try Botox, because you’ve tried everything else.’ And it might work. It may not work; it may not give you the results that you want. But it may be enough to just pull you back from the edge because some there aren’t, they’re really on the edge.

[Jaz]
But the important thing is that you’ve made the diagnosis, and then you’ve made the link. Okay, this is one way additionally to manage this diagnosis that you have. And that’s what you know, keeps your confidence going. ‘Okay, it’s still worth giving a go.’ It’s not like ‘Oh, you tried everything and try.’ It’s because they’ve actually got a diagnosis of myalgia based on your examination and history.

[Sheila]
Yeah. And what I would say as well, sometimes as well, because they might come in and like say, ‘Look, I tried Botox, it didn’t work.’ And often, if there is a true muscular component, this is likely due to the Botox, but not being injected well, at the right depth. But often it’s injected far too superficially, if the muscles is really bulky or is really thick, it needs to be injected deep, almost on the bone, you know, hit the bone slightly pullback and inject. And so, if it’s failed in the past, that won’t be my reason for me to discount treating them. I will say, ‘Look, let’s give it a try.’ Maybe it’s because it was injected in the right place. Maybe they didn’t inject the right muscle. Maybe they didn’t use as big a dose.

I actually often find that we’re not using a high enough dose to treat when it comes to TMD and when it comes to pain. For cosmetic reasons completely different, but when it comes to TMD and pain, I find that they need a much, much higher dose. And where a high dose comes in, a bigger increase of side effects and adverse events happens. And that’s why dentists tend to pull back slightly and under treat. But patients in pain, they want a result. They’re paying a lot for it. They definitely want results. So, yeah, it may be that you just need to try again. We need to make sure we’re getting the right muscle and we’re injecting high enough. But not so high that we’re causing a complication as well.

[Jaz]
Have you had Botox in your masseters? If you don’t mind me asking?

[Sheila]
I have. Look. It’s coming back. It needs more.

[Jaz]
I know you mentioned that in the webinar, actually.

[Sheila]
I’m a clencher. I’m a clencher.

[Jaz]
Yes, you said I remember. Now, when you’ve had it, can you just speak from your first hand experience? What does it feel like to have it the day after, in terms of eating. What difference does one feel?

[Sheila]
So, immediately after, it feels tight and sore, because actually it’s a stress. Your reaction to having any injection is to clench and make it even worse. So, the trauma of having the Botox itself, it feels a little bit bruised, a little bit sore, a little bit uncomfortable. But kind of very similar to a really deep intense sports massage. You feel a bit battered afterwards. But as it starts to kick in, you feel a sense of weakness in the muscle. Now, there is an absolute reduction in the ability to bite very, very hard, chewy things. So, I found around about day five to seven, chewing a steak felt really, really different to what it would normally feel like. And it’s really great that I’ve had this because I can actually relate to this and explain to the patient, ‘Look, around about five to maybe even 10 days, you might feel an intense weakness in your jaw.’ That’s the goal, you’re supposed to feel that, because I’m just retraining your muscles to use your jaw muscles, the way they’re supposed to be used. Not in this hyperactive way that you have been using them.

So, you will feel some weakness. You’ll feel like it’s loose. That’s probably the best way to describe it. But you will get used to it. When you take two weeks and you’ll forget about it. Takes two weeks to adjust to that new sensation. And you can tell when it starts to kick in because you’ll wake up or you’ll start to feel the tension again. Usually, I’ve had it injected in my masseters. You’ll start to feel, for me, the tension headaches, and the tightness in my jaw when I feel like I’m starting to need it again.

[Jaz]
Have you ever injected Botox into someone with a beard like mine?

[Sheila]
Yeah, I wouldn’t expect you to shave. We would just make sure it’s really nice and clean. And what’s really important is, that you need to feel the muscles but yeah, it’s fine. You don’t have to shave that all.

[Jaz]
Fine. Good, good, good.

[Sheila]
You have to clean it really well.

[Jaz]
Yes. I have very hypertrophic masseter muscles. So, you never know, I might. You know, I’ve tried virtually most splints. I teach about it and talk about it. And so, if I ever go down to Serbia bit, that’d be nice to experience it, right? So, on that note then, it’s the final question, actually, it just leads me nicely, okay. If I have it, do you expect any side effects, and then also, any side effects long-term?

[Sheila]
So the biggest, long-term side effect is the atrophy of the muscle, which we’re actually trying to achieve. So, it’s the point of Botox injections. Now, on a man who has a beautiful square jawline, because of their huge masseters, it’s one of the things that we have to counsel them and explain to them, ‘Look, you’re going to lose your excessive jawline, unfortunately.’

[Jaz]
Thank you.

[Sheila]
But you know, I want to get you out of pain. And I also want to make sure that you’re not going to have lots of restorations in the future. So, you know, it’s your jawline versus your teeth. And I’m always going to choose your teeth over your jawline. So, you do have to explain that to the patient, because, of course, we’re creating atrophy of the muscles. So, you’re going to get that reduction. You’re going to get the facial shape changes. Now, in a man, that’s not desirable. In a woman, that is desirable. But when a woman, what they need to be warned about is, if they’ve got any looseness and laxity in their skin, they’re going to end up with worse than an older woman. They may exacerbate their gels, which isn’t great for women. They don’t love that. They really get annoyed if you haven’t pre-warned them about that.

[Jaz]
So it’s like a turkey neck but the angle of the mandible.

[Sheila]
Yeah, sort of more along the jaw line, so it hangs a little bit more. And that doesn’t happen to everybody. It’s more likely in patients with lacks loose skin tissue, older patients with skin tissues. And that’s the long-term effects. If you’re repeatedly over treating, and of course, you’re going to get beyond this, we’re going to get excessive atrophy of the muscle and then really weak patients are not gonna be able to chew. That’s not what we never get to that point because we always buy nine months in, we’re reassessing. And then, actually, that’s why we’re increasing our duration of treatment time to six to nine months. The sort of short term side effects that you can get if you don’t place the Botox in the right place, or if you inject it too superficially, or you inject far too much volume or in the wrong places. Things like a asymmetry in their smile. That’s not ideal. The patients get really annoyed and you can’t correct it. The only thing you can do is go out and take the other side out. Or you reassure them by telling them that it’s going to get better in six weeks time and smile restriction as well. If you’ve gone too forwards with the injections or you’ve injected too superficially, you’ll get some restrictions. Sometimes they have to accept that if they’re in severe pain. I say to them, ‘Look, I have to use a big dose. We have to accept that you may get some smile restriction, not asymmetry.’ The restriction is something they feel, not necessarily something they see. They will feel that they can’t smile as wide. But usually to other people, it’s not something that’s noticeable. So, for the first time, we may just accept it.

The second time, we may modify and reduce the dose depending on how much atrophy they’ve got. But it’s something that I can send patients for. And inevitably, not everybody gets a small restriction because there’s a muscle resource and not every single patient has resource. But in some patients where you want to inject the full depth and muscle, really deep, but more superficial as well. Then they will, to a certain degree, have a restriction. There’s more, that’s something you have to warn. Also, a small number of patients, I believe it’s one in 300, may get a headache following the Botox treatments, and it’s quite a severe headache. You have to warn them about that in the last a couple of days. It seems to be only the first time that they have the toxin injection. We think it’s due to the relaxation, or maybe the trauma from the actual injections themselves. But it’s quite severe, and you have to warn them about that. Other than that, all the other things really, really-

[Jaz]
So it’s like toxin in the masseter but then they get a headache not necessarily toxin in the temporalis, right? Toxin in the masseter.

[Sheila]
In a masseter, yes. As a side effect to that.

[Jaz]
What about bone resorption? Is that something that worries you long-term chronic use?

[Sheila]
So, bone resorption, we’re thinking about more to do with the fact that the patient is not able to know the reason for bone resorption. It’s really difficult for the evidence when we’re looking at this because if we think about the bone resorption, that’s happening anyway, that’s an aging process, every single patient will get bone resorption. So, that’s my first argument. The second one is, that it’s more linked to the fact that they’re not utilizing and not having teeth in the back of them. So, that’s going to exacerbate bone resorption from a perspective of masseter treatment. For me, it doesn’t make any sense that they would get bone resorption with overall long-term use because you’re not completely taken away that in their ability to chew and bite. You’re just reducing that force. So for me, it’s not a risk and bone resorption happens anyway, as we age. It’s a natural part of the aging process.

[Jaz]
Okay, brilliant. No, I think it’d be covered a lot of ground there. Sheila, if anyone wants to learn from you how to do these things or into facial aesthetics or functional. How did you go about doing that? Because I know I’ve been attended a couple of webinars and stuff. Tell the world of dentists listening right now, how they can reach out to you and learn because you’re such an inspiring teacher. You’re so passionate about this. You’ve done the whole restorative dentistry now. You’ve niched into it. Tell us where can learn more from you?

[Sheila]
Thanks, Jaz! So, I do have a functional toxin course just for dentists to treat functional elements. Reach out to me, head over to my website, mediject.co.uk, and you can fill in a form. But I also have a quick guide to what we’ve discussed today as well. So, quick guide to TMD management with Botox. So, if anyone is listening, you want a quick guide on the steps for assessment diagnosis, what to say to the patient, the treatment options, including the risks and benefits, head over to the website and just send me a form and title it ‘Protrusive Podcast’ and I can send you that 10 point guide just to help you treatment plan. I’ll also include the little screening tool as well, for those of you who don’t actually do any treatments for TMD specifically, but you want to be more knowledgeable and refer onwards. That is a really, really useful tool that I find. It’s great to add into sort of like your medical history for or your new patient assessment. It’s really great for that. So yeah.

[Jaz]
It’s great that someone on the dental forum for Dan’s Biden has actually commented saying, posted it, ‘Look, I’m actually not interested in facial aesthetics. I want to learn functional.’ And then people are like, ‘Well, actually, with these other institutions, you have to do like four levels first, before you can do the functional bit.’ But it’s great that you recognize the value and importance of general dentists who are treating functional issues day in day out to add this to their armamentarium is a good thing. And I respect you a lot for teaching this. That’s amazing!

[Sheila]
Thank you, Jaz. Yes, and there is a need for it. And it can be done really well. It’s really straightforward. And once you understand how Botox works, where the anatomy lies, and what to do. And of course, you know, having somebody to support you. You mentioned, you make sure that you are doing things properly, will mean that you will get predictable results. And actually, again, as I said, learning how you need to be able to prescribe and to be able to make splints as well as part of this is one of the most important things.

[Jaz]
All work with someone closely who does this things, if you don’t want to do it, right?

[Sheila]
Yes, if you don’t want to do it. Yes, absolutely! But assessment and diagnosis are crucial and you will learn all of that and I will teach you that and I’ll guide you through that whole process.

[Jaz]
Amazing guys. Head on over to, is it MEDIJECT?

[Sheila]
MEDIJECT, M-E-D-I, ject, J-E-C-T.co.uk.

[Jaz]
Amazing! Fill in the form. Tell Sheila in her subject, Jaz says hi or something Protrusive. And then get this download and start a conversation Sheila. Keep in touch when the time is right for you. You should totally learn about these functional things and you never know you might go to facial aesthetics. For those listening to this podcast, probably you clicked on because, ‘Oh, someone talked about masseters let’s listen.’

[Jaz]
Sheila, thank you so much for giving up your time. I really appreciate it. I know you’re such a busy clinician, busy mom. It’s great to have you. We’re going to be seeing you on our monthly grind on the sixth of July. So, our monthly SplintCourse live webinar. We’re gonna do is specifically for the group of dentists who have done or are doing splint course. And they know a little bit extra than the average dentist about TMD. So, we’re niching down a little bit, and we will cover some themes from today, but then some more specific ones. And it’d be great for you to share some cases on that evening as well.

[Sheila]
Yes, I will do. I can’t wait! I’m really looking forward to that. Thank you Jaz for having me.

Jaz’s Outro:
Thank you, Sheila. Well, there we have it, guys. Thanks for listening all the way to the end. If you want to reach out to Sheila, then go to the show notes on the website. Or if you scroll down on your native player sometimes, for example, on Google podcasts, you scroll down, you see all this sort of text, all the links, my YouTube video, etc. But if you’re on a platform where you can’t see the show notes, then I always advise going to the main website. You can even download and see all the transcripts for all the episodes. So, for this one, it will be protrusive.co.uk. That will take you to the notes for this episode, and the transcript at the bottom and a link to reach out to Sheila. And if you’re a dentist who’s already using Botox to help their patients with myofascial pain, and TMJ issues. And perhaps you’re looking to level up when it comes to occlusal appliances, especially if you’re not already harnessing the power of things like B splints and how to provide them safely without worrying about AOBs. Then check out my flagship online course, www.splintcourse.com to guide you through that set of appliances, diagnosis and everything in between. Thanks again for listening all the way to the end and next time you see dentists arguing about which cases are suited for Botox and which ones aren’t. Send them a link to this podcast. Thank you again!