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J Am Dent Assoc, Vol 131, No 2, 211-216.
© 2000 American Dental Association
Essential Dental System, Inc.
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CLINICAL PHARMACOLOGY

JADA Continuing Education

TREATING SEVERE BRUXISM WITH BOTULINUM TOXIN



ENG-KING TAN, M.D. and JOSEPH JANKOVIC, M.D.


   ABSTRACT
TOP
 ABSTRACT
SUBJECTS AND METHODS
 RESULTS
 CASE REPORTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Background. Locally administered botulinum toxin, or BTX, is an effective treatment for various movement disorders. Its usefulness in treating bruxism, however, has not been systematically evaluated.

Subjects and Methods. The authors studied 18 subjects with severe bruxism and whose mean duration of symptoms was 14.8 ± 10.0 years (range three–40 years). These subjects audibly ground their teeth and experienced tooth wear and difficulty speaking, swallowing or chewing. Medical or dental procedures had failed to alleviate their symptoms. The authors administered a total of 241 injections of BTX type A, or BTX A, in the subjects’ masseter muscles during 123 treatment visits. The mean dose of the BTX A was 61.7 ± 11.1 mouse units, or MU (range 25–100 MU), per side for the masseter muscles.

Results. The mean total duration of response was 19.1 ± 17.0 weeks (range six–78 weeks), and the mean peak effect on a scale of 0 to 4, in which 4 is equal to total abolishment of grinding, was 3.4 ± 0.9. Only one subject (5.6 percent) reported having experienced dysphagia with BTX A.

Conclusion. The results of this study suggest that BTX administered by skilled practitioners is a safe and effective treatment for people with severe bruxism, particularly those with associated movement disorders. It should be considered only for those patients refractory to conventional therapy. Future placebo-controlled studies may be useful in further evaluating the potential of BTX in the treatment of bruxism.

Bruxism is a diurnal or nocturnal parafunctional activity that includes tooth clenching, bracing, gnashing and grinding.1 Its prevalence rates range from 5 to 96 percent in the adult population.2–5 Differences in the methodology and the definitions of bruxism used in different studies contribute to the varied reported prevalence rates.

Bruxism is of great interest to dentists, oral surgeons, psychologists, neurologists, primary care physicians and others who provide treatment. Although many etiologic factors such as stress and occlusal disorders have been proposed,2,6–7 bruxism’s exact pathophysiology still is unknown.

Bruxism has been reported in certain neurological disorders such as Rett syndrome,8 mental retardation,9 anoxic encephalopathy10 and cerebellar hemorrhage.11 Tooth clenching, grinding or both have been reported to be particularly prevalent in patients with idiopathic, tardive and post-traumatic cranial dystonia, which is a neurological disorder manifested by abnormal spasms and movements involving the orolingualfacial musculature.12–14 The majority of these patients had diurnal symptoms, though some had both diurnal and nocturnal symptoms.12 These symptoms appear to be different than those of subjects with nocturnal grinding frequently reported in the dental literature.

Various treatment modalities have been reported to be useful for bruxism,2,15–20 but there is no general agreement as to what is the best therapeutic option.

Botulinum toxin, or BTX, is the most potent known biological toxin and is a safe and effective for treatment of various forms of neurological disorders.21,22 Training guidelines have been established for the use of BTX.23–25 This neurotoxin is produced by the anaerobic bacterium Clostridium botulinum and exerts its paralytic effects by inhibiting the release of acetylcholine at the neuromuscular junction. The toxin is a zinc endopeptidase that cleaves one or more proteins in the docking of the acetylcholine with the presynaptic membrane, thus inhibiting the release of the acetycholine into the neuromuscular junction. This results in local chemodenervation and focal muscle weakness.

Seven antigenically distinct types of BTX have been recognized: A, B, C, D, E, F and G. Type A, which cleaves the plasma protein SNAP-25, is the most common commercially used type of BTX, but clinical experience with types B, C and F is increasing.26

BTX is administered by intramuscular injection, and its effects last an average of three to six months. The extent of this transient denervation is dependent on the dose and volume of the toxin.

The unit of measurement for BTX type A, or BTX A, is the mouse unit, or MU. One MU is equivalent to the amount of toxin found to kill 50 percent of a group of 18- to 20-gram female Swiss Webster mice. The usual maximum recommended dose is 300 to 400 MU per session and not more than 400 MU per three-month period. The dose, however, varies depending on the size of the target muscle, the intensity of contraction and other factors such as response to the initial treatment.

To date, no anaphylaxis or deaths attributable to BTX A have been reported. BTX is contraindicated in patients with neuromuscular disease, who are receiving aminoglycosides or who are pregnant or lactating. Long-term effects of BTX are mild and may include alterations in muscle fiber size.27

No known reports exist on quantified results; however, there have been a few anecdotal reports demonstrating the effectiveness of BTX in patients with bruxism.28–30

In an open-label prospective study, we evaluated the effectiveness and complications of BTX A (BOTOX, Allergan Inc.) treatment in patients with severe bruxism. These patients’ bruxism was manifested by diurnal or nocturnal tooth grinding, and a majority of them had associated movement disorders.


   SUBJECTS AND METHODS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
RESULTS
 CASE REPORTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
We included in the study patients who were evaluated at Baylor College of Medicine’s Parkinson’s Disease Center and Movement Disorders Clinic over an eight-year period, who complained of teeth clenching and grinding as their predominant symptoms, and who satisfied the following diagnostic criteria: tooth-grinding sounds corroborated by family members or caregivers; difficulty in chewing, swallowing or speech; tooth wear; receipt of medical therapies and dental procedures that failed to alleviate bruxism; and pain or hypertrophy of masseter muscles from palpation during a clinical examination. In addition to the diagnosis of bruxism, we required at least one follow-up evaluation after BTX treatment. We excluded patients with histories of severe trauma to the jaw, dental surgeries or both that preceded their bruxism, as we were not sure whether the procedures were performed to treat the bruxism or for other reasons such as to treat trauma.

A total of 18 subjects, 17 of whom were women, met our criteria to participate in the study. Their mean age was 50.6 ± 20.7 years (range 18–80 years), and the average time they had experienced bruxism was 14.8 ± 10.0 years (range three–40 years). The mean duration of follow-up was 3.3 ± 2.8 years (range 0.4–eight years). All of the subjects had diurnal or nocturnal tooth grinding or both, but the majority had predominant diurnal symptoms. The most common associated movement disorder was dystonia (Table 1Go).


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  		TABLE 1 FEATURES IN SUBJECTS WITH BRUXISM.

 
Before we administered BTX injections, the subjects were required to sign a written informed consent form that had been approved by Baylor College of Medicine’s Institutional Review Boards for Human Research.

We placed each subject in the supine position, localized the muscles by careful palpation and then injected BTX A in the masseter muscles—the active muscles that caused the grinding—at two to three sites. We administered a total of 241 BTX A injections in the subjects’ masseter muscles during 123 treatment visits—121 injections in the right masseter muscles and 120 injections in the left masseter muscles. The mean dose of BTX A was 61.7 ± 11.1 MU (range 25–100 MU) per side for the masseter muscles. (The formulation and preparation of BTX A have been described previously.21) The mean time interval between BTX A treatments was 5.0 ± 1.8 months (range 3.2–9.7 months).

We also administered BTX A injections in the relevant muscles of 14 subjects who had evidence of associated dystonia—a clinical diagnosis defined as muscle spasm resulting in abnormal posturing—in other anatomical regions (face, neck, and arms and legs) on clinical examination.

We defined latency of response of BTX A’s effect as the number of days between the injection and the first sign of improvement after the injection. We defined peak effect as the maximum benefit obtained from the injection; it was rated on a scale of 0 to 4 (0 = no effect, 1 = mild improvement, 2 = moderate improvement but no change in function, 3 = moderate improvement in severity and function, and 4 = marked improvement in severity and function). We determined each subject’s peak effect after a careful review of his or her daily diary (a self-assessment of severity of symptoms) and own perception of response, as well as interviewing his or her spouses and friends. We defined the maximum duration of response as the number of weeks during which the subjects experienced peak effect and defined total duration of response as the entire period after the injection was administered during which subjects experienced any improvement.

We collected the following information and entered it into a database:

– demographic data;
– etiology of bruxism;
– duration of bruxism;
– associated dystonia or movement disorders in other body parts;
– family history of bruxism or movement disorders;
– site and number of BTX A injections;
– mean and cumulative muscle dose;
– number of treatment visits;
– number of subjects and treatment visits with complications;
– types, duration and severity of complications;
– response to BTX—measured by peak effect—latency to response and maximum and total duration of response.


   RESULTS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
CASE REPORTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
The subjects’ mean latency to response was 2.7 ± 1.7 days (range 0.5–five days). Their mean maximum and total duration of response were 11.7 ± 4.1 weeks (range 2.5–18 weeks) and 19.1 ± 17 weeks (range six–78 weeks), respectively. The mean peak effect of BTX was 3.4 ± 0.9 (range 0–4).

Only one subject (5.6 percent) reported experiencing an adverse effect—dysphagia—with BTX A, and some adverse effects were noted at six of the 123 treatment visits (4.9 percent). The mean duration of complications was 34.7 ± 7.0 days (range 21–40 days).


   CASE REPORTS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
 CASE REPORTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Case 1. A 79-year-old woman with a long history of bipolar disorder came to Baylor College of Medicine’s Parkinson’s Disease Center and Movement Disorders Clinic because she walked slowly and had abnormal mouth and tongue movements. In addition, she complained of experiencing severe tooth grinding for three years. The audible grinding sounds that occurred day and night regularly disturbed her family members. She experienced severe tooth wear, particularly on her mandibular teeth, and underwent various dental procedures, including insertion of dentures. This treatment temporarily alleviated her grinding, but the relief did not last. Her speech and swallowing were affected by the severe grinding. She had been prescribed various pharmacological therapies by her physicians but had not experienced any relief.

When we examined her, we noted that she had mild parkinsonian symptoms and a symptomatic shuffling gait, as well as stereotypical movements of her tongue and mouth. Audible tooth-grinding sounds were noted at the time of examination. She also had jaw tenderness and bilateral masseter muscle spasms on clinical palpation. Although she was diagnosed with early Parkinson’s disease, her parkinsonism and severe bruxism were likely secondary to neuroleptic usage, as she had a history of exposure to neuroleptics for treatment of her bipolar disorder, and she had tongue and mouth movement suggestive of tardive dyskinesia.

We injected 60 MU of BTX A in each of both masseter muscles, as well as 10 MU of BTX in the submentalis muscle because of presence of a mild spasm in this muscle.

She reported improvement of her grinding within few days, and it gradually stopped one month after the injection. Her jaw pain also resolved, and she was able to speak and swallow without problems. She did not receive any further BTX A injections. At one and one-half years after she received BTX A treatment, her grinding did not recur, though there were a few episodes of tooth clenching.

Case 2. We examined a 19-year-old woman with cerebral palsy and seizures secondary to perinatal anoxia at the clinic. Abnormal muscle spasms in her face, neck, and arm and leg muscles had developed by time she was two years of age. She had experienced tooth wear resulting in broken teeth that had been restored. Her evaluation stemmed from grinding that was mostly intermittent, though there were occasions when she would grind continuously throughout the day. Her parents had noticed audible tooth-grinding sounds predominantly during the day.

When we examined her, we found the presence of eyelid muscles spasms (blepharospasm) and mild neck and limb muscles spasms, and heard grinding sounds. She had jaw tenderness and bilateral masseter muscle spasms on clinical palpation.

We injected 50 MU of BTX in each of both masseter muscles, as well as 30 MUs of BTX in her eyelid and brow muscles.

Her parents reported that her grinding improved by at least 75 percent within a day of the injection. The improvement had lasted for four months.


   DISCUSSION
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
 CASE REPORTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
While no central nervous system structures associated with teeth grinding have been identified, it has been speculated that, in some cases, bruxism may be a part of dystonia and share similar pathophysiology.12 A higher prevalence rate of bruxism has been reported in cranial-cervical dystonia compared with normal controls.12 Patients with neurological disorders such as Rett syndrome and anoxic encephalopathy or who are in a comatose state might have more severe bruxism.

It has been postulated that the activation of phasic jaw activity depends on the interaction among the motor, limbic and autonomic systems, resulting in either disinhibition or facilitation of a "central bruxism generator."31 There is evidence of anatomical connections between the limbic system, pontine reticular formation and the trigeminal motor nucleus.32

How a single dose of BTX A injection in the masseter muscles totally abolishes severe bruxing behavior, as illustrated in our first case report, is intriguing. There also has been a reported case of total resolution of bruxism—caused by a brain injury—after a single injection of BTX.28 We speculate that jaw muscle paralysis induced by BTX A may disrupt the feedback loop from the trigeminal motor nucleus and inhibit the central bruxism generator. Alternatively, it also may deactivate periodontal mechanoreceptors during mastication, which have been thought to have a facilitatory effect on jaw closure motoneurons.33


   CONCLUSIONS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
 CASE REPORTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
This study of 18 subjects with severe bruxism provides evidence that BTX A administered appropriately into the masseter muscles is a safe and effective treatment for this condition.

The subjects had experienced their symptoms for a mean of 14.8 years before the initial injection. Before BTX A treatment, the subjects’ bruxism had failed to respond to various medical therapies and dental procedures, providing further evidence of its severity (Table 1Go). Marked relief of grinding and functional improvement in chewing, swallowing or speaking was reported in 16 subjects (88.9 percent) after BTX A treatment. The mean latency to response of action of BTX was relatively short (2.7 days) in our subjects, and the total effect of each injection lasted up to a mean of 19.1 weeks (Table 2Go). On the average, subjects needed BTX A injections at a regular interval of five months; each time a mean dose of about 62 MU per side was injected in the masseter muscles. This dose was, on average, higher than the treatment we gave to patients with jaw closing dystonia in a previous study.21 We did not administer BTX A in the temporalis muscles of our subjects and do not know if this would have further improved the results.


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  		TABLE 2 TREATMENT, RESPONSE AND COMPLICATIONS OF BOTULINUM TOXIN TYPE A.

 
The treatment complication rate was low. Only one subject (5.6 percent) reported experiencing transient dysphagia, which did not require change of diet after we injected the BTX A. This complication constituted only six of the 123 treatment visits (4.9 percent) in the study. The complication rate was comparable to that of patients with dystonia treated with BTX in our previous study.21

A chief difficulty in assessing the severity of bruxism and a response to therapy is the lack of consensus on the definition of bruxism; a validated severity scale is not available. Based on various criteria used in the literature,20 we had defined severe bruxism in those with daily audible teeth grinding as corroborated by family members or caregivers.

All of the subjects in the study were partially disabled by the bruxism because of impaired chewing, swallowing or speaking; tooth wear; and temporomandibular joint tenderness or hypertrophy of the masseter muscles on palpation. While this study has shown that BTX A is effective for treating severe bruxism, it must be pointed out that our subjects appear to be more affected by bruxism than patients with nocturnal symptoms who are frequently encountered in a dental practice. Most of the subjects in this study had associated diurnal movement disorders such as dystonia.

In summary, our study of a select group of subjects (the majority of whom had associated movement disorders) has demonstrated that BTX A injections can be a safe and effective treatment for severe tooth grinding. It is, however, an expensive treatment and should be considered as a therapeutic option only for those who have complicated or disabling bruxism and are refractory to other medical and dental therapy. BTX A should be administered only by clinicians with knowledge of its pharmacology and the relevant anatomy of the sites to be injected. Experience and skill in the techniques of injections will minimize the risk of unnecessary complications. Future placebo-controlled studies may be useful to further evaluate the potential of BTX A treatment in bruxism.


   FOOTNOTES
 

Dr. Tan is a visiting fellow, Parkinson’s Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston. He also is an associate consultant, SGH Brain Center, Department of Neurology, Singapore General Hospital.


Dr. Jankovic is a professor and the director, Parkinson’s Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, 6550 Fannin Smith 1801, Houston, Texas 77030. Address reprint requests to Dr. Jankovic.


Dr. Jankovic received grant support and an honorarium from Allergan Inc.


   REFERENCES
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
 CASE REPORTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

  1. American Academy of Orofacial Pain. Temporomandibular disorders: Guidelines for classification, assessment, and management. 2nd ed. Chicago: Quintessence; 1993.

  2. Thompson BA, Blount BW, Krumholz TS. Treatment approaches to bruxism. Am Fam Physician 1994;49(7):1617–22.[Medline]

  3. Solberg WK, Woo MW, Houston JB. Prevalence of mandibular dysfunction in young adults. JADA 1979;98(1):25–34.[Abstract]

  4. Glaros AG. Incidence of diurnal and nocturnal bruxism. J Prosthet Dent 1981;45(5): 545–9.[Medline]

  5. Pavone BW. Bruxism and its effect on the natural teeth. J Prosthet Dent 1985;53(5): 692–6.[Medline]

  6. Lindqvist B. Bruxism and emotional disturbance. Odontol Revy 1972;23(2):231–42.[Medline]

  7. Rugh JD, Harlan J. Nocturnal bruxism and temporomandibular disorders. In: Jankovic J, Tolosa E, eds. Advances in neurology. New York: Raven Press; 1988:329–41.

  8. FitzGerald PM, Jankovic J, Percy AK. Rett syndrome and associated movement disorders. Mov Disord 1990;5(3):195–202.[Medline]

  9. Richmond G, Rugh JD, Dolfi R, Wasilewsky JW. Survey of bruxism in an institutionalized mentally retarded population. Am J Ment Defic 1984;88(4):418–21.[Medline]

  10. Pratap-Chand P, Gourie-Devi M. Bruxism: its significance in coma. Clin Neurol Neurosurg 1985;87(2):113–7.[Medline]

  11. Pollack IA, Cwik V. Bruxism following cerebellar hemorrhage. Neurology 1989;39(9): 1262.[Free Full Text]

  12. Wooten-Watts M, Tan EK, Jankovic J. Bruxism and cranio-cervical dystonia: is there a relationship? Cranio 1999;17:196–201.[Medline]

  13. Sankhla C, Lai EC, Jankovic J. Peripherally induced oromandibular dystonia. J Neurol Neurosurg Psychiatry 1998;65(5): 722–8.[Abstract/Free Full Text]

  14. Tan EK, Jankovic J. Tardive and idiopathic oromandibular dystonia: a clinical comparison. J Neurol Neurosurg Psychiatry (in press).

  15. Quinn JH. Mandibular exercises to control bruxism and deviation problems. Cranio 1995;13(1):30–4.[Medline]

  16. Mohamed SE, Christensen LV, Penchas J. A randomized double-blind clinical trial of the effect of amitriptyline on nocturnal masseteric motor activity (sleep bruxism). Cranio 1997;15:326–32.[Medline]

  17. Sjoholm TT, Lehtinen I, Piha SJ. The effect of propranolol on sleep bruxism: hypothetical considerations based on a case study. Clin Auton Res 1996;6(1):37–40.[Medline]

  18. Lobbezoo F, Soucy JP, Hartman NG, Montplaisir JY, Lavigne GJ. Effects of the D2 receptor agonist bromocriptine on sleep bruxism: report of two single-patient clinical trials. J Dent Res 1997;76(9):1610–4.[Abstract/Free Full Text]

  19. Lobbezoo F, Lavigne GJ, Tanguay R, Montplaisir JY. The effect of catecholamine precursor L-dopa on sleep bruxism: a controlled clinical trial. Mov Disord 1997;12(1): 73–8.[Medline]

  20. Hathaway KM. Bruxism: definition, measurement, and treatment. In: Friction JR, Dubner R, eds. Orofacial pain and temporomandibular disorders. New York: Raven Press; 1995:375–86.

  21. Jankovic J, Schwartz K, Donovan DT. Botulinum toxin treatment of cranial-cervical dystonia, spasmodic dysphonia, other focal dystonias and hemifacial spasm. J Neurol Neurosurg Psychiatry 1990;53(8):633–9.[Abstract/Free Full Text]

  22. Jankovic J, Brin M. Therapeutic uses of botulinum toxin. N Engl J Med 1991;324: 1186–94.[Medline]

  23. American Academy of Ophthalmology. Botulinum toxin therapy of eye muscle disorders: safety and effectiveness. Ophthalmology 1989;September(pt 2):37–41.

  24. Clinical use of botulinum toxin: National Institutes of Health Consensus Development Conference statement. Arch Neurol 1991;48:1294–8.[Abstract/Free Full Text]

  25. Training guidelines for the use of botulinum toxin for the treatment of neurologic disorders: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 1994;44(12):2401–3.[Free Full Text]

  26. Jankovic J, Brin MF. Botulinum toxin: historical perspective and potential new indications. Muscle Nerve Suppl 1997;6:S129–45.[Medline]

  27. Brin MF. Botulinum toxin: chemistry, pharmacology, toxicity, and immunology. Muscle Nerve Suppl 1997;6:S146–68.[Medline]

  28. Ivanhoe CB, Lai JM, Francisco GE. Bruxism after brain injury: successful treatment with botulinum toxin-A. Arch Phys Med Rehabil 1997;78(11):1272–3.[Medline]

  29. Van Zandijcke M, Marchau MM. Treatment of bruxism with botulinum toxin injections. J Neurol Neurosurg Psychiatry 1990; 53:530.[Free Full Text]

  30. Rijsdijk BA, van ES RJ, Zonneveld FW, Steenks MH, Koole R. De toepassing van botuline A toxine bij cosmetisch storende M.-masseterhypertrofie. [Botulinum toxin type A treatment of cosmetically disturbing masseteric hypertrophy]. Ned Tijdschr Geneeskd 1998;142(10):529–32.[Medline]

  31. Hartmann E. Bruxism. In: Kryger MH, Roth T, Dement WC, eds. Principles and practice of sleep medicine. 2nd ed. Philadelphia: Saunders; 1994:598–601.

  32. Takeuchi Y, Satoda T, Tashiro T, Matsushima R, Uemura-Sumi M. Amygdaloid pathway to the trigeminal motor nucleus via the pontine reticular formation in the rat. Brain Res Bull 1988;21(5):829–33.[Medline]

  33. Lavigne G, Kim JS, Valiquette C, Lund JP. Evidence that periodontal pressoreceptors provide positive feedback to jaw closing muscles during mastication. J Neurophysiol 1987;58(2):342–58.[Abstract/Free Full Text]




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