Efficacy of Botulinum Toxin Versus Lidocaine in Treating Masticatory Myofascial Face Pain Using Ultrasound and EMG Guided Techniques

Study Description

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Brief Summary:

Botulinum toxin-A (BTX-A) prevents the release of acetylcholine in presynaptic terminals of the neuromuscular junction. It has been proposed to be effective in spastic conditions of the head and neck including oromandibular dystonias, bruxism, and muscular hypertrophy (1,2,3,4). However, only one randomized, double-blinded, placebo controlled trial has been completed involving 20 patients demonstrating both objective and subjective improvement in the BTX-A treated group over those treated with saline at one week, one month, and six months (5).

Currently, in most orofacial pain practices, when the diagnosis of masticatory myofascial pain in the head region is made, patients are treated with a standard myofascial protocol. This protocol involves stretching, application of moist heat, spray and stretch, and lidocaine trigger point injections into the masticatory muscles. This is considered the standard of care among most orofacial pain practioners.

There have been no randomized, double-blinded, head-to-head trials comparing BTX-A injections to lidocaine injections in the treatment of masticatory myofacial pain. Moreover, in all studies, muscles were targeted using surface landmarks with no confirmatory tests to guarantee the medication was administered to the intended muscle. In previous studies, the medial and lateral pterygoid muscles, important masticatory muscles that is often hyperactive in masticatory myofacial pain was not injected due to lack of palpable surface landmarks. Ultrasound and electromyography (EMG) guidance will help us locate these muscles.

The purpose of this study is to objectively measure functional improvement in patients with masticatory myofascial pain injected with lidocaine versus BTX-A. A pilot study enrolling 20 patients is proposed. 20 patients will be randomized to receive either BTX-A or lidocaine injections into the bilateral temporalis, masseter, and medial and lateral pterygoid. Objective and subjective clinical parameters will be measured. These include pain at rest and with chewing, maximum non-assisted and assisted mouth opening, protrusive and laterotrusive jaw movements, subjective efficacy of treatment, and side-effects of treatment. Patients will be assessed at baseline, one week, one month, and three months after the procedure.

Condition or disease	Intervention/treatment	Phase
Face Pain	Drug: lidocaine; Drug: chemodenervation	Phase 4

Study Design

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Study Type :	Interventional (Clinical Trial)
Actual Enrollment :	17 participants
Allocation:	Randomized
Intervention Model:	Parallel Assignment
Masking:	Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary Purpose:	Treatment
Official Title:	Efficacy of Botulinum Toxin Versus Lidocaine in Treating Masticatory Myofascial Face Pain Using Ultrasound and EMG Guided Techniques
Study Start Date :	October 2009
Actual Primary Completion Date :	October 2010
Actual Study Completion Date :	October 2010

Arms and Interventions

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Study Description Study Design Arms and Interventions Outcome Measures Eligibility Criteria Contacts and Locations More Information

Arm	Intervention/treatment
Active Comparator: Lidocaine; lidocaine injection group	Drug: lidocaine; 1cc 1%
Experimental: Botulinum	Drug: chemodenervation; botulinum toxin

Outcome Measures

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Primary Outcome Measures :

1. Clinical Response as Assessed by >20% Change From Baseline in the Jaw Functional Limitation Scale (JFLS) Global Score [ Time Frame: 4 months ]
   The JFLS contains 20 items that measure limitations across mastication, vertical jaw mobility, and verbal/emotional expression rated on a 0-10 scale where 0 = "no limitation" and 10 = "severe limitation."

Secondary Outcome Measures :

1. Clinical Response as Assessed by >20% Change From Baseline in the Jaw Functional Limitation Scale (JFLS) Global Score [ Time Frame: 6 weeks ]
   The JFLS contains 20 items that measure limitations across mastication, vertical jaw mobility, and verbal/emotional expression rated on a 0-10 scale where 0 = "no limitation" and 10 = "severe limitation."
2. Clinical Response as Assessed by >20% Change From Baseline in the Pressure Pain Threshold [ Time Frame: baseline, 4 months ]
   measurements were obtained by placing examiner's index finger of the examiner on the area of the trigger point (hyperirritable areas on skeletal muscle with palpable taut bands of muscle fibers) and exerting pressure until there was whitening of the nail bed. Pressure pain levels were rated subjectively by the participant and coded numerically as mild (1), moderate (2) to severe (3).
3. Clinical Response as Assessed by >20% Change From Baseline in Jaw Opening [ Time Frame: baseline, 4 months ]
   maximum mandibular range of motion scores (measured as the maximum interincisal distance and compensating for occlusion)

Eligibility Criteria

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Ages Eligible for Study:	18 Years to 65 Years (Adult)
Sexes Eligible for Study:	All
Accepts Healthy Volunteers:	Yes

Criteria

Inclusion Criteria:

• Subjects are to have identifiable painful myofascial trigger points in the masseter, temporalis, and medial and lateral pterygoid muscles.
• Subjects will be examined by the principle investigators to determine if the individual is a suitable candidate for the study, based on active trigger points and willingness to participate in the study

Exclusion Criteria:

• Pregnant woman will be excluded from participation as potential risk is noted in product label indications. Individuals over the age of 65 will be excluded per product label indications that reflect lack of data in individuals over age 65.

Contacts and Locations

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Locations

United States, California
Westwood Associates
Los Angeles, California, United States, 90024

Sponsors and Collaborators

University of California, Los Angeles

Investigators

Principal Investigator:	Marisa Chang, M.D.	University of California, Los Angeles

More Information

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Study Description Study Design Arms and Interventions Outcome Measures Eligibility Criteria Contacts and Locations More Information

Responsible Party:	University of California, Los Angeles
ClinicalTrials.gov Identifier:	NCT00992108 History of Changes
Other Study ID Numbers:	8295968
First Posted:	October 9, 2009
Results First Posted:	December 29, 2016
Last Update Posted:	December 29, 2016
Last Verified:	November 2016

Keywords provided by University of California, Los Angeles:

Bruxism; Myofascial pain; EMG; Ultrasound; Masticatory myofascial face pain from bruxism and clenching

Additional relevant MeSH terms:

Facial Pain; Pain; Neurologic Manifestations; Nervous System Diseases; Signs and Symptoms; Lidocaine; Botulinum Toxins; Anesthetics, Local; Anesthetics; Central Nervous System Depressants; Physiological Effects of Drugs	Sensory System Agents; Peripheral Nervous System Agents; Anti-Arrhythmia Agents; Voltage-Gated Sodium Channel Blockers; Sodium Channel Blockers; Membrane Transport Modulators; Molecular Mechanisms of Pharmacological Action; Acetylcholine Release Inhibitors; Cholinergic Agents; Neurotransmitter Agents