Overview of TMD and MMP
Temporomandibular Joint Disorder (TMD) and Masticatory Myofascial Pain (MMP) are conditions where there is dysfunction of the temporomandibular joint (TMJ) and surrounding muscles often presenting as pain or limitations in movement. TMD is a disease of the bones and ligaments associated with the TMJ and definitive treatment requires alteration of these structures. MMP on the other hand is associated with the muscles of mastication – masseters, temporalis, and pterygoid muscles – with the goal of treatment is to alter how the muscles function. Both TMD and MMP can present as facial pain with patients often having a combination of the two conditions.
Conservative Therapy
The initial step in treatment of TMD/MMP is seeing your general dentist. Your dentist will perform an exam and may order x-rays to determine what degree TMD and MMP play a role in your facial pain. Conservative treatment options include:
- stress reduction
- soft food diet
- cold or warm compresses to your face
- jaw opening stretches and exercises
- anti-inflammatory medications
- referral to a physical therapist to help retrain your jaw
- a prescription for a muscle relaxant
- fabrication of bite splint or mouthguard
Conservative therapies are reversible and depending on the severity of your TMD/MMP, may resolve your pain and symptoms.
Neurotoxins for Myofascial Pain
Neurotoxins (NT) are medications that limit the contraction of muscles. They are often used cosmetically to help with facial wrinkles, but they play a role in MMP as well. One of biggest contributors to MMP is bruxism – clenching and grinding your teeth. Bruxism often occurs unconsciously both when we are awake as well as asleep. Some signs and symptoms of bruxism are flattening of your teeth, large masseter muscles (square jaw line), and soreness of your jaws and temples.
If you continue to have jaw pain despite conservative therapy and your dentist has diagnosed you with bruxism, neurotoxins may be a good option for you. NTs work by limiting the activation of some of your muscle fibers. You will still be able open, close, and chew food, but the forces used for these actions will be less. The effects of NT treatment last for approximately 3-6 months, with some patients reporting longer results with repeated treatments. It is important to understand that neurotoxins should be used in conjunction with other treatments as it usually treats the symptoms, but not necessarily the cause of your bruxism.
Which Muscles Can be Treated by Neurotoxin for Bruxism?
There are four muscles responsible for jaw function – the masseters, temporalis, medial pterygoids, and lateral pterygoids. The muscles generally treated are the masseters and temporalis. They are usually the larger of these muscles, more easily accessed, and easier to isolate compared to the pterygoids.
Will Neurotoxin Help with TMD?
If your pain and symptoms are primarily from TMD, neurotoxins will have limited benefit for you. As mentioned, NT help deactivate muscle function and TMD is primarily a bone and ligament issue so will not directly help your symptoms. If you continue to have pain due to TMD despite conservative management, you will need to seek out an oral and maxillofacial surgeon that treats TMD. We do not treat TMD at South Austin Oral Surgery.
What Can I Expect After Neurotoxin Injections for Bruxism?
You can return to you regular activities after your injections. The injections themself take only a couple of minutes. You may have some soreness initially and apply ice to the area. NT to the masticatory muscles take a little bit longer to take effect compared to other facial muscles, but the muscles should feel more relaxed within 1-2 weeks. For your first visit, Dr. Raju prefers to use a smaller dose and repeat the injections at 3-4 weeks to better tailor the appropriate dose for you. Too much NT can result in a change in your facial shape so a balance between esthetics and function must be found.
Which Neurotoxins can be used for Bruxism?
The neurotoxins used for bruxism are the same as those that can be used for cosmetics – Botox, Jeuveau, Dysport, and Xeomin. All of the medications consist of the botulinum toxin and an associated protein (or lack of one). They each have their uses and nuances, however at South Austin Oral Surgery, Dr. Raju uses Botox Cosmetic, Botox Medical, and Jeuveau.
Botox Cosmetic and Botox Medical are the same medication, however are FDA approved for different uses (cosmetics or medical treatment). Both have the same effect and many patients prefer using Botox Cosmetic for their bruxism treatment as it comes in smaller size and as a result lower cost. Jeuveau is supposedly a different formulation than Botox, however was developed by former employees of Allergan (the creators of Botox) and weighs the same at the molecular level as Botox. It seems to have the same effects and length of treatment as Botox as well. Jeuveau is also only FDA approved for cosmetic reasons. They all work well for bruxism.
What is the Cost of Neurotoxin Injections for Bruxism?
At South Austin Oral Surgery, you will initially require an exam and panorex xray. These are often covered by medical insurance, however you will be responsible for copays and deductibles. Depending on the availability of your desired medication, we may be able to provide treatment on the same day as your exam. If your symptoms are primarily due to TMD, it is recommended you see a TMD specialist for further management.
The cost of treatment is based on the type and amount of neurotoxin used. The neurotoxin medications and costs used at South Austin Oral Surgery are as follows:
- Jeuveau 50 units – $600
- Botox Cosmetic 50 units – $700
- Jeuveau 100 units – $1000
- Botox Medical 100 units – $1200
Dr. Raju does not offer neurotoxin treatment on a per unit basis. Most patients will need about 50 units. 100 units is generally used for patients with exceptionally large muscles or those also seeking to receive treatment for facial cosmetic reasons.
Will Insurance Cover Neurotoxins for TMD/MMP?
Insurance sometimes covers neurotoxin injections for TMD/MMP. You will need to contact your insurer directly to see if they cover your treatment and ask what is their “criteria for medical necessity.” You will often need specific diagnosis and procedure codes.
Diagnosis codes often used by our office in diagnosing bruxism are:
- myalgia of mastication muscles (M79.11)
- myalgia of auxillary muscles, head & neck (M79.12)
- painful bruxism (other somatoform disorder) (F45.8)
- headache, unspecified (R51.9)
- jaw pain (R68.84)
- limited mandibular range of motion (M26.52)
- sleep related bruxism (G47.63)
The procedure codes used are:
- chemodenervation of facial muscles (64615)
- Botox injection, 100 units (J0585)
While the codes used for the procedure are fairly standard, we are unable to provide you with specific diagnosis codes until your exam.
If your medical insurance states they provide coverage for you, we will provide you with an itemized bill that you can submit to your insurance. Please note that if you would like to submit for insurance coverage, we will can only use Botox Medical 100 units ($1200) for your care. You will need to pay this amount up front and submit and collect any payments directly from your insurance company. Our office does not file medical insurance claims at this time.
Call (512) 692-7140 or email us to schedule your appointment today.