Effectiveness of Botulinum Toxin Injection on Bruxism: A Systematic Review and Meta-analysis of Randomized Controlled Trials

[Translated article] Botulinum Toxin for Aesthetic Use in Facial and Cervical Regions: A Review of the Techniques Currently Used in Dermatology

Botulinum toxin infiltration is one of the most widely performed aesthetic procedures at the aesthetic dermatology office. Although infiltrative techniques have been known for quite a few years, several changes have been described so far, mainly based on anatomical knowledge. There are consensus guidelines available for injecting neuromodulators where one can see both the doses of toxin indicated for each muscle and the injection techniques. After a systematic review of the articles currently available, this article intends to summarize the infiltration techniques described both for the face and neck, while considering new anatomical considerations, new injection techniques published to date, and pearls and tricks for a better understanding of how to inject the botulinum toxin and improve our injection techniques. In our opinion it is important to treat the lower third to complement the treatment of the upper third and, in some patients, the partial blocking of some muscles of the middle third. With this comprehensive treatment of face and neck muscles we can achieve more natural and harmonious results.

Botulinum Toxin for Aesthetic Use in Facial and Cervical Regions: A Review of the Techniques Currently Used in Dermatology

Botulinum toxin infiltration is one of the most widely performed aesthetic procedures at the aesthetic dermatology office. Although infiltrative techniques have been known for quite a few years, several changes have been described so far, mainly based on anatomical knowledge. There are consensus guidelines available for injecting neuromodulators where one can see both the doses of toxin indicated for each muscle and the injection techniques. After a systematic review of the articles currently available, this article intends to summarize the infiltration techniques described both for the face and neck, while considering new anatomical considerations, new injection techniques published to date, and pearls and tricks for a better understanding of how to inject the botulinum toxin and improve our injection techniques. In our opinion it is important to treat the lower third to complement the treatment of the upper third and, in some patients, the partial blocking of some muscles of the middle third. With this comprehensive treatment of face and neck muscles we can achieve more natural and harmonious results.

The Role of Botulinum Toxin for Masseter Muscle Hypertrophy: A Comprehensive Review

Masticatory muscle hypertrophy (MMH) is a rare clinical phenomenon of uncertain etiology, characterized by a soft swelling near the angle of the jaw. This abnormal enlargement of the masseter muscle can alter the facial profile, leading to aesthetic concerns. Moreover, MMH may also have significant functional repercussions, including pain in the masseter region, often associated with temporomandibular disorders, fatigue, and discomfort during mastication. Non-conservative approaches offer an effective and minimally invasive solution by inducing localized muscle relaxation and reducing hypertrophy. Botulinum neurotoxin type A (BoNT/A) represents a therapeutic option for managing MMH, considering that injections can effectively reduce the masseter muscle volume, improving both facial aesthetics and related symptoms. Currently, the standard non-surgical management of MMH is BoNT/A injections, although consensus on the average dosage has not been definitely reached; on the other hand, there are data available in the literature about the injection technique of BoNT/A for lower face contouring. Therefore, the present comprehensive review aimed at exploring in detail the role of BoNT/A in the treatment of masseter muscle hypertrophy, describing its mechanism of action, the administration protocols, the clinical effects, and any side effects.

Efficacy of oral and non-oral migraine prophylactic treatment on self-reported subjective sleep quality in migraine patients with sleep problems: A review and meta-analysis

This study aims to investigate the effects of oral and non-oral migraine prophylaxis on subjective sleep quality in migraine patients with sleep problems. A bidirectional relationship between migraine and sleep is presumed, although this relationship is not fully clarified. Possibly, prophylactic treatment of migraine aiming at a reduction of migraine attack frequency can also positively affect the quality of sleep for patients with migraine with sleep problems. PubMed, Cochrane, Embase and CINAHL databases were searched in March 2022 for studies evaluating prophylactic treatment of migraine and the impact on perceived sleep quality (Pittsburgh Sleep Quality Index or Insomnia Severity Index). A systematic review using the McMaster Tool and a random-effects meta-analysis (effect size Cohen's d) were conducted. Seven studies were identified, including 989 participants, of which 844/989 (85.3%) female, with a mean (SD) age of 41.3 (12.1) years. In 6/7 (85.7%) studies, monthly migraine days improved (p < 0.002). Five out of six (83.3%) studies presented a relevant improvement in quality of sleep (p < 0.05), and one study reported a clinically meaningful improvement in the treatment group (Insomnia Severity Index change >7, in >50% of participants). The meta-analysis showed a large effect size of 1.09 (95% confidence interval 0.57-1.62; overall p < 0.001; Cochran's Q < 0.0001) for migraine prophylaxis on improving sleep quality. In conclusion, prophylactic migraine treatment improves sleep quality in patients with migraine and sleep problems, as measured with self-reported questionnaires Pittsburgh Sleep Quality Index and Insomnia Severity Index. Unfortunately, some included studies used prophylactic treatment that is not in current (international) guidelines. The evidence for this improvement in quality of sleep is strong, and seems a generic effect of migraine prophylaxis.

Occlusal splint or botulinum toxin-a for jaw muscle pain treatment in probable sleep bruxism: A randomized controlled trial

OBJECTIVES

To conduct an equivalency randomized controlled trial comparing occlusal splint (OS) and botulinum toxin-A (BTX-A) on jaw muscle pain in probable sleep bruxism.

METHODS

Sixty patients (≥18 years, probable sleep bruxism, and jaw muscle pain) were randomly allocated into groups. The primary outcome was the reduction of jaw muscle pain, assessed using the Graded Chronic Pain Scale (GCPS, v2.0). Secondary outcomes included: parameters of jaw opening and mandibular mobility; distribution of muscle pain; Jaw Functional Limitation Scale-20 (JFLS-20), Oral Behaviors Checklist (OBC); and Oral Health Impact Profile-14 (OHIP-14). Only the evaluator was blinded. Multilevel mixed-effects regression models were used.

RESULTS

Fifty-nine patients (30 received OS and 29 BTX-A) were analyzed at baseline, 3 and 6 months follow-up. One patient dropped out after receiving the intervention. No differences between the interventions were observed concerning the GCPS (p = 0.627), although a significant reduction was observed at 3 (OR=13.26, 95%CI[6.61-26.59]) and 6 months (OR=12.36, 95%CI[4.93-30.98]), regardless of the treatment. BTX-A showed a lower score reduction on JFLS-20 than OS (OR=0.29, 95%CI[0.11-0.82]). BTX-A presented inferior results for the parameters: opening without pain(p = 0.045), unassisted maximum opening(p = 0.024), assisted maximum opening(p = 0.041), and protrusion(p = 0.016). An improvement in OHIP-14 scores was observed at 3 (IRR=1.08, CI95%[1.02-1.14]) and 6 months (IRR=1.10, CI95%[1.04-1.16]), regardless of the intervention. BTX-A participants(n = 23;79,3%) reported mild discomfort during chewing.

CONCLUSION

OS and BTX-A can effectively decrease the GCPS scores, improve OHRQoL, and enhance functional outcomes in sleep bruxist patients with jaw muscle pain. OS demonstrated slight advantages in specific parameters.

CLINICAL SIGNIFICANCE

Both occlusal splints and botulinum toxin-A effectively reduce jaw muscle pain in bruxist patients, improving quality of life and mandibular function. Clinically, occlusal splints may offer additional benefits in specific functional parameters. (NCT03456154).

Botulinum toxin for the management of bruxism: an overview of reviews protocol

INTRODUCTION

Bruxism is characterised by a repetitive activity in the masticatory muscles that involves teeth clenching or grinding and/or forceful mandibular movements. Its management is typically initiated when individuals start experiencing the adverse effects of the condition. One of the available intervention forms is the administration of botulinum toxin type A (BoNT-A). Numerous systematic reviews have addressed the use of BoNT-A to manage bruxism; however, the results are controversial. The current overview aims to determine BoNT-A's effectiveness for managing bruxism in relation to placebo, the absence of treatment or alternative interventions in the adult population.

METHODS AND ANALYSIS

This study will include systematic reviews (SRs), with or without meta-analysis, aiming to evaluate the efficacy of BoNT-A for bruxism in adults. A broad literature search will be carried out on Cochrane Library, EMBASE, LILACS, Livivo, PubMed/MEDLINE, Scopus, Web of Science and the grey literature. Experts in the topic and reference lists of included SRs will also be consulted. The study selection will be conducted in two phases by two independent reviewers. Data collection will be performed by one author and cross-checked by another. The methodological quality of included SRs will be evaluated using AMSTAR-II. A narrative synthesis will be employed as the formal method to combine individual study data. The overlap across studies will be quantified by the corrected covered area and illustrated by the Graphical Representation of Overlap for Overviews.

ETHICS AND DISSEMINATION

This overview does not require ethics approval, as it uses secondary data from previously published studies. The results will be disseminated through the publication in a high-impact journal.

OSF OF REGISTRATION

DOI: 10.17605/OSF.IO/RB45T.

Botulinum toxin for bruxism treatment: a nationwide study among oral and maxillofacial surgeons in Germany

INTRODUCTION

This study aimed to evaluate the use of botulinum toxin (BTX) for the treatment of bruxism in oral and maxillofacial surgery in Germany.

MATERIAL AND METHODS

A dynamic online questionnaire comprising 7 to 25 questions was formulated to gather general and specific information regarding using BTX to treat bruxism. The questionnaire underwent internal and external assessments for validation. Subsequently, it was distributed to 906 oral and maxillofacial surgeons (OMFS) affiliated with the German Association for Oral and Maxillofacial Surgery (DGMKG). Weekly reminders were dispatched over four weeks to enhance response rates. Participation in the study was voluntary and anonymized. Descriptive methods were employed for data analysis.

RESULTS

107 OMFS participated in the study, yielding a response rate of 11.81%. On average, 17 patients with bruxism were per month, with 4 of these patients receiving BTX therapy. BTX administration was frequently accompanied by splints and physiotherapy (35.51% of participants). Botox® (Allergan) was the preferred BTX preparation, utilized by 40.79% and reconstituted with saline by 92.11% of participants. The masseter muscles were primarily targeted for BTX treatment (67.57% of participants), averaging 29 BTX (Allergan-) units per side. Injection points for each masseter muscle typically amounted to six per side, preferred by 30.67% of participants. Follow-up assessments post-BTX treatment were conducted regularly, predominantly after four weeks, by 36% of participants. In 8% of cases, additional BTX injections were necessary due to inadequate outcomes. Side effects were reported in 4% of cases, commonly manifesting as a non-disturbing reduction in bite force. Most participating OMFS (61.84%) using BTX for bruxism therapy regarded bruxism treatment with BTX as evidence-based. Notably, 97.37% of respondents expressed their willingness to recommend BTX-based bruxism treatment to their colleagues. Overall, the efficacy of BTX therapy for bruxism was rated as good (53.95%) and very good (40.79%).

CONCLUSION

The use of BTX for the management of bruxism among OMFS in Germany has demonstrated efficacy. Substantial variances in certain facets of bruxism treatment employing BTX have been observed.

CLINICAL RELEVANCE

Additional research endeavors are warranted to comprehensively investigate distinct elements of BTX therapy for bruxism, including the optimal dosage of BTX units and the precise localization of injection sites across various muscles.

Botulinum Toxin-A for the Treatment of Myogenous Temporomandibular Disorders: An Umbrella Review of Systematic Reviews

OBJECTIVE

Temporomandibular disorders (TMDs) encompass several conditions that cause pain and impair function of the masticatory muscles (M-TMDs) and temporomandibular joints. There is a large interest among clinicians and researchers in the use of botulinum toxin-A (BoNT-A) as a treatment for M-TMD. However, due to the lack of consistent evidence regarding the efficacy as well as adverse events of BoNT-A, clinical decision making is challenging. Therefore, this umbrella review aimed to systematically assess systematic reviews (SRs) evaluating BoNT-A treatment effects on pain intensity, mandibular movements, and adverse events in patients with M-TMDs.

METHOD

An electronic search was undertaken in the databases MEDLINE, EMBASE, CINAHL, Cochrane Central Registry of Controlled Trials (CENTRAL), Web of Science, Epistemonikos, ClinicalTrials.gov, and ICTRP to identify SRs investigating BoNT-A effects on M-TMDs, published from the inception of each database until 6 December 2023. The quality of evidence was rated according to the critical appraisal checklist developed by the umbrella review methodology working group. Only high-quality SRs were included.

RESULTS

In total, 18 SRs were included. BoNT-A was shown to be more effective than placebo to reduce pain intensity, but not compared to standard treatments. Additionally, BoNT-A was not superior to placebo or standard treatments regarding improvement of mandibular movements. BoNT-A was considered to have a higher risk for adverse events on muscle and bony tissue compared with other treatments.

CONCLUSION

The synthesis in this umbrella review provides the highest level of evidence present. Taken together, there are indications of effectiveness of BoNT-A for treatment of M-TMDs, supported by moderate evidence. However, considering the risk of causing serious adverse events, treatment with BoNT-A is recommended to be the last treatment alternative.

Bibliometric Analysis of Botulinum Toxin and Bruxism: Impact, Visualization, and Collaborative Networks

AIM

To analyze the scientific production related to the use of botulinum toxin (BTX-A) in the management of bruxism and evaluate its scope, impact, networks, and new research trends.

MATERIALS AND METHODS

A descriptive and retrospective study of publications indexed in Scopus from January 2018 to May 2024 was conducted. The bibliometric indicators evaluated were a number of publications, citations, h-index, SCImago Journal Rank 2022, CiteScore 2022, Lotka's Law, Bradford's Law, and keyword co-occurrence analysis. Data were processed using SciVal and VOSviewer.

RESULTS

We obtained 98 publications, including original articles, reviews, and other types of documents. Among the most productive authors, most were from South Korea and Turkey. Wonkwang University (South Korea) had the highest number of publications, while Baylor College of Medicine (USA) had the highest impact with 66.5 citations per publication. Toxins had the highest number of publications and the best Cite Score in 2022. Six main topics related to BTX-A in bruxism were identified, highlighting "reviews," "electromyography" and "controlled clinical trials".

CONCLUSIONS

The use of BTX-A for the treatment of bruxism has generated increasing interest and scientific output in recent years, especially in South Korea and Brazil. However, there is a disparity in the productivity of authors, with most authors presenting only one publication.

CLINICAL SIGNIFICANCE

This study highlights the need for further research and collaborations to optimize clinical practice and better understand the efficacy and management of BTX-A for treating bruxism. How to cite this article: Villanueva-García M, Ruck-Sanchez N, Tinedo-López PL, et al. Bibliometric Analysis of Botulinum Toxin and Bruxism: Impact, Visualization, and Collaborative Networks. J Contemp Dent Pract 2024;25(6):599-604.

Effects of different interventions on bruxism: an overview of systematic reviews

OBJECTIVE

This study aimed to evaluate, qualify, and summarize evidence presented in systematic reviews (SR) on treatments for bruxism.

METHODS

The overview was conducted using the PICO strategy: children, adolescents, and adults with bruxism (P) were submitted to different treatments (I) compared to other treatments, placebo, or no treatment (C) in order to evaluate incidence, prevalence, and number of episodes of bruxism (O). The search was carried out in six databases and gray literature up to July 2023. Data were extracted, and the ROBS tool was used, followed by a descriptive synthesis of the results.

RESULTS

A total of 31 SR were included. Sixteen showed a positive effect on episodes of bruxism (BE), while two had negative, one had neutral, and nine had inconclusive effects. Using the risk of bias in systematic reviews tool (ROBIS), risk of bias varied from low (n = 23) to high (n = 5) among the SR. Pharmacological treatment, oral rehabilitation, and other therapeutic approaches presented inconclusive or negative effects on BE, while oral appliances showed controversial effects. Biofeedback, physical therapy, laser therapy, and botulinum toxin showed positive effects on the reduction of BE.

CONCLUSION

Biofeedback, physical therapy, laser therapy, and botulinum toxin showed positive effects on the reduction of BE; there is still a lack of studies to support the safe and long-term use of these therapies.

REGISTRATION NUMBER

PROSPERO CRD42021273905.

Efficacy and Safety of Botulinum Toxin in the Management of Temporomandibular Symptoms Associated with Sleep Bruxism: A Systematic Review

Sleep bruxism, characterized by involuntary grinding or clenching of teeth during sleep, poses significant challenges in management due to its potential to induce temporomandibular joint disorders (TMDs) and other related symptoms. The use of Botulinum toxin Type A (BoNT-A), also known as Botox®, has been proposed as a therapeutic intervention. This systematic review aims to evaluate the efficacy and safety of BoNT-A in the management of sleep bruxism, focusing on pain reduction, improvement in jaw function, reduction in bruxism episodes, and the incidence of adverse effects. An exhaustive search was conducted across PubMed, Scopus, and Embase databases up to January 2024, adhering to the PRISMA guidelines. Nine randomized clinical trials (RCTs) involving 137 participants were analyzed for efficacy and safety outcomes. The studies demonstrated a significant reduction in mean pain scores (from 7.1 to 0.2 at 6 months and 1 year post-treatment in one study) and a notable decrease in the number of bruxism events (from 4.97/h to 1.70/h in the BoNT-A group in another study). Additionally, improvements were observed in jaw stiffness and total sleep time. Adverse effects varied but were generally mild and transient, including injection site pain in 20% of participants in one study and cosmetic changes in smile in 15.4% of patients in another. These findings suggest that BoNT-A injections may provide some benefits for treating nocturnal bruxism, potentially reducing TMD symptoms like pain and improving jaw function. However, these findings are preliminary due to variability in study designs and the absence of detailed statistical analysis.

Botulinum Toxin-Induced Parotitis: A Postoperative Complication Following Masseter Muscle Injection

Botulinum toxin (BTX) injection is a common treatment for bruxism, but there is no literature on potential salivary gland complications. This paper presents a case of acute parotitis in a 60-year-old female following BTX injections to the masseter muscle. This case highlights the possible salivary gland complications after injection of BTX into the masticatory muscles. An electronic search of PubMed and Embase databases was conducted to create a literature review in order to delve into the etiology behind the presented case and suggest potential preventive measures to avoid salivary gland complications. Thirty-one articles are reviewed and discussed. Currently, there is no consensus on the causes of the mentioned complication. However, various factors have been proposed, encompassing anatomical, physiological, biological, and physical aspects. Several methods have been recommended for the safe injection of BTX, which, along with better medical training and knowledge, are warranted to achieve predictable results.

Can botulinum toxin injection alleviate the pain of bruxism? A Bayesian network analysis and a single-arm analysis

Background/purpose

There is inconsistent evidence regarding whether the botulinum toxin A (BTA) injection can relieve pain caused by bruxism. This study aimed to estimate the efficiency of BTA injection in relieving pain caused by bruxism at different follow-up periods.

Materials and methods

Five electronic databases were searched from 2005 to 2022 using search terms related to botulinum toxin and bruxism. Only controlled clinical trials were included. Two investigators reviewed each article and discussed any disagreements until a consensus was reached. Pain outcomes as evaluated by the visual analogue scale (VAS) were subjected to single-arm and Bayesian network meta-analyses. Pooling data were measured by a random-effects model.

Results

Eleven studies with a total of 365 bruxism patients were included. According to the single-arm analyses of the pooled data, the reduction in bruxism-related pain after BTA injection measured 4.06 points (95% CI = 3.37 to 4.75) on the VAS, and the pain relief was significant in the first 6 months after treatment (P < 0.01). According to the Bayesian analysis, BTA also resulted in significantly greater pain relief than oral splinting (mean difference (MD), -1.5; 95% credible interval (CrI) = -2.7 to -0.19) or saline injection (MD, -3.3; 95% CrI = -6.2 to -0.32).

Conclusion

BTA significantly relieves the pain of bruxism for 6 months after injection, and its therapeutic efficacy was higher than that of oral splinting. Nevertheless, further long-term follow-up randomized controlled trials comparing BTA with other management or drugs are warranted.

Sleep Bruxism in Children: A Narrative Review

Sleep bruxism, characterized by involuntary grinding or clenching of the teeth and/or by bracing or thrusting of the mandible during sleep, is common in children. Sleep bruxism occurs while the patient is asleep. As such, diagnosis can be difficult as the affected child is usually unaware of the tooth grinding sounds. This article aims to familiarize physicians with the diagnosis and management of sleep bruxism in children. A search was conducted in May 2023 in PubMed Clinical Queries using the key terms "Bruxism" OR "Teeth grinding" AND "sleep". The search strategy included all observational studies, clinical trials, and reviews published within the past 10 years. Only papers published in the English literature were included in this review. According to the International classification of sleep disorders, the minimum criteria for the diagnosis of sleep bruxism are (1) the presence of frequent or regular (at least three nights per week for at least three months) tooth grinding sounds during sleep and (2) at least one or more of the following (a) abnormal tooth wear; (b) transient morning jaw muscle fatigue or pain; (c) temporary headache; or (d) jaw locking on awaking. According to the International Consensus on the assessment of bruxism, "possible" sleep bruxism can be diagnosed based on self-report or report from family members of tooth-grinding sounds during sleep; "probable" sleep bruxism based on self-report or report from family members of tooth-grinding sounds during sleep plus clinical findings suggestive of bruxism (e.g., abnormal tooth wear, hypertrophy and/or tenderness of masseter muscles, or tongue/lip indentation); and "definite" sleep bruxism based on the history and clinical findings and confirmation by polysomnography, preferably combined with video and audio recording. Although polysomnography is the gold standard for the diagnosis of sleep bruxism, because of the high cost, lengthy time involvement, and the need for high levels of technical competence, polysomnography is not available for use in most clinical settings. On the other hand, since sleep bruxism occurs while the patient is asleep, diagnosis can be difficult as the affected child is usually unaware of the tooth grinding sounds. In clinical practice, the diagnosis of sleep bruxism is often based on the history (e.g., reports of grinding noises during sleep) and clinical findings (e.g., tooth wear, hypertrophy and/or tenderness of masseter muscles). In childhood, sleep-bruxism is typically self-limited and does not require specific treatment. Causative or triggering factors should be eliminated if possible. The importance of sleep hygiene cannot be over-emphasized. Bedtime should be relaxed and enjoyable. Mental stimulation and physical activity should be limited before going to bed. For adults with frequent and severe sleep bruxism who do not respond to the above measures, oral devices can be considered to protect teeth from further damage during bruxism episodes. As the orofacial structures are still developing in the pediatric age group, the benefits and risks of using oral devices should be taken into consideration. Pharmacotherapy is not a favorable option and is rarely used in children. Current evidence on the effective interventions for the management of sleep bruxism in children is inconclusive. There is insufficient evidence to make recommendations for specific treatment at this time.

Natural Products and Pharmacological Properties of Symbiotic Bacillota (Firmicutes) of Marine Macroalgae

The shift from the terrestrial to the marine environment to discover natural products has given rise to novel bioactive compounds, some of which have been approved for human medicine. However, the ocean, which makes up nearly three-quarters of the Earth's surface, contains macro- and microorganisms whose natural products are yet to be explored. Among these underexplored marine organisms are macroalgae and their symbiotic microbes, such as Bacillota, a phylum of mostly Gram-positive bacteria previously known as Firmicutes. Macroalgae-associated Bacillota often produce chemical compounds that protect them and their hosts from competitive and harmful rivals. Here, we summarised the natural products made by macroalgae-associated Bacillota and their pharmacological properties. We discovered that these Bacillota are efficient producers of novel biologically active molecules. However, only a few macroalgae had been investigated for chemical constituents of their Bacillota: nine brown, five red and one green algae. Thus, Bacillota, especially from the marine habitat, should be investigated for potential pharmaceutical leads. Moreover, additional diverse biological assays for the isolated molecules of macroalgae Bacillota should be implemented to expand their bioactivity profiles, as only antibacterial properties were tested for most compounds.