Dissertation on Dentistry

This dissertation explores the effectiveness of Botulinum Toxic A (BTX-A) in treating temporomandibular joint disorder. It includes a literature review, search strategy, databases used, key search terms, and more. The study aims to determine the relationship between BTX-A and conventional splint therapy in treating temporomandibular joint disorder.

Dissertation on Dentistry

TABLE OF CONTENTS
CHAPTER 1: LITERATURE REVIEW.........................................................................................3
INTRODUCTION...........................................................................................................................3
Literature search strategy.............................................................................................................3
Databases.....................................................................................................................................3
Search engines.............................................................................................................................4
Key search terms..........................................................................................................................4
Boolean operators........................................................................................................................4
Inclusion and exclusion criteria...................................................................................................5
Temporomandibular Myofascial Pain.........................................................................................5
Effectiveness of Botulinum Toxic A (BTX-A) in treating temporomandibular joint disorder...6
REFERENCES................................................................................................................................8

CHAPTER 1: LITERATURE REVIEW
INTRODUCTION
A careful and through literature review is very essential to carry out an investigation in
the right direction. It can be considered a basic homework that is assumed to have been done
attentively and gives deep insights of different facts and figures of research papers on similar
topic. With the help of the systematic literature review, it becomes easy for the researchers to
address the investigation issues and get the solutions of the research questions. It introduces the
broad context to research issues and minimize the duplication of existing studies. Along with
this, it allows the investigators to determine the relationship between the different
methodologies, outcomes etc to extract the right information from the previous researches. The
present chapter is related to literature review of determine effectiveness of Botulinum Toxic A
(BTX-A) as compared to conventional splint therapy in treating temporomandibular joint
disorder. In this context, the different objectives will be covered by the scholar by considering
and taking help of old research papers on similar topic.
Literature search strategy
A systematic process has been used by the researcher in order to find out the suitable
literature for the present dissertation topic on determining the effectiveness of Botulinum Toxic
A (BTX-A) as compared to conventional splint therapy in treating temporomandibular joint
disorder. The literature search process has included selected key words, electronic database,
deciding inclusion and exclusion criteria etc (Schoels, Knevel and et.al., 2010).
Databases
In order to select appropriate literature, electronic databases have been taken into the
consideration by the scholar. The reason behind using these is to retrieve the useful information
from the different sources in minimum time (Coumou and Meijman, 2006). It has contained
large number of journals articles and act wide sources of information. Therefore, database have
helped the investigator to obtain relevant studies for the present research on identifying the
effectiveness of Botulinum Toxic A (BTX-A) as compared to conventional splint therapy in
treating temporomandibular joint disorder. By this, the researcher has assisted to conduct the

following investigation in appropriate way (Visser and van der Heijde, 2008). The database that
has been use in present study is as follows:
Databases Description
Psych-INFO It is the largest resources in the world that include peer- reviewed more than 4
million bibliographic records based on mental health and behavioural science.
It is the most highly utilized database that use by the students, researchers,
practitioners, educators etc across the world (PsycINFO, 2016).
MEDLINE It is a bibliographic database that comprises academic journals covering on a
wide range of topics such as nursing, health care, medicines and dentistry
(Medline, 2016).
CINAHL This is an index of journals relating to nursing, biomedicine, healthcare and
allied health (CINAHL Database, 2016).
Search engines
To search the literature review on the similar topic, the researcher has been used perch
engine such as EBSCOhost. It is an electronic journal host and encloses journals of large number
of different publishers across the world. The following search engine allows the scholar to search
for articles from the vast collection of journals (Riesenberg, Leisch and Cunningham, 2010).
Key search terms
Key search terms can be defined as the chief variables which assists the researchers to
carry out a particular research on an identified issue. In order to repossess relevant journals and
articles for a specific investigation, it is essential to determine and chose various key search
terms (Schoels, Knevel and et.al., 2010). In the context of the present dissertation, there have
some key search terms which has been used to reclaim journal articles on the identified research
issues:
TERM 1 Effectiveness, efficiency, efficacy, helpfulness
TERM 2 Botulinum toxin type A, (BTX-A)
TERM 3 Splint therapy
TERM 4 Temporomandibular joint disorder, TMJ, TMD,

Boolean operators
Boolean operators are words “AND”, “OR” and “NOT” which are used to define logical
relationships between search terms. It helps in making the research more accurate and specific.
For the present research on temporomandibular joint disorder, Boolean operator OR has been
used by the researcher to expand the research (Coumou and Meijman, 2006).
Inclusion and exclusion criteria
After selection of the key search terms, the investigator has been taken the decision of
inclusion and exclusion criteria for the investigation. In the present research on
temporomandibular joint disorder, the inclusion and exclusion criteria is as follows:
Inclusion criteria Exclusion criteria
Journal articles published in English Research studies carried out in any other
language.
Research studies conducted from 2000- 2016 Researches done prior to 2000
Research studies on effectiveness of
Botulinum toxin type in treating
temporomandibular joint disorder
Research carried out on effectiveness of
Botulinum toxin type in treating other kind of
disorders
Research studies on effectiveness of splint
therapy in treating temporomandibular joint
disorder
Research studies on effectiveness of splint
therapy in treating other kind of disorders.
Temporomandibular Myofascial Pain
Myofascial pain syndrome is also called as myofascial pain and dysfunction syndrome
that occurs in patients with a normal temporomandibular joint. It is basically caused by tension,
fatigue or spasm in the masticatory muscles (Kim, Yun and Kim, 2016). Its symptoms include
bruxism, pain and tenderness in and around the masticatory apparatus. Health care practitioners
diagnose it on the basis of historical records and physical examination. The syndrome is
considered as the most common disorder that affects the temporomandibular region. It is also
common among women and it also has a bimodal age distribution in the early 20s and during
menopause (Fortuna, Vaz and et.al., 2011). The temporal mandibular joint is the synovial joint
that connects the jaw to the skull and these two joints are located just in front of each ear. It is
also believed that MPD syndrome is a physical manifestation of psychological stress. Pain is
secondary to these events such as nocturnal jaw clenching and teeth grinding.
It has been identified that up to 30% adults experience TMD at some point in their lives;
the condition is not usually serious and can be managed with the help of suitable care and

exercises (Sahai, Dowson, Khan and et.al., 2010). However, on the basis of symptoms, patients
can lead to lower quality of life. At the same time, specialist treatment is required if the condition
is severe. Earaches and toothaches are directly associated with the masseter which is a trigger
point that radiates pain directly into the tooth. Thus, it is clear that temporomandibular joint
syndrome is a failure of jaw joint function that is mostly painful. This also limits the movement
of the jaw and specific problem arises during sleeping, eating and talking. Functional
disturbances are common in TMJ (Bohluli, Motamedi and et.al., 2011). Internal derangement is
also caused through the joint pain where in the problem lies in the joint and most commonly in
articulating disc.
Effectiveness of Botulinum Toxic A (BTX-A) in treating temporomandibular joint disorder
As per the study of Kerscher, Roll, Becker and Wigger-Alberti, 2012, “Botulinum toxin
type A (BTX-A) is a 150 kDa protein produced by the bacterium Clostridium botulinum”
(Kerscher, Roll, Becker and Wigger-Alberti, 2012). The following toxin is internalized into
presynaptic cholinergic nerve terminals where it release the neurotransmitter acetylcholine which
restraining the contraction of muscles. By considering the muscle relaxant properties, BTX-A
uses to treat variety of muscular conditions and it includes spasticity, cervical dystonia and
blepharospasm. In this context, Ernberg, Hedenberg-Magnusson, List, and Svensson, 2011 has
stated that “the first effectiveness of BTX-A in treating temporomandibular joint disorder is
decompression of entrapped nerves in patient” (Ernberg, Hedenberg-Magnusson, List, and
Svensson, 2011). With the help of this, it becomes easy to relaxation to muscles by deep
massage. It also helps in increasing the motion and stretching of muscles at the time of treating
temporomandibular joint disorder. In order to correct postural asymmetries and to stabilize the
musculature, BTX-A is design to strengthen and supporting co-contracting muscles. The
following treatment has effective in terms of breaking the cycle of pain, to attain neuromuscular
re-education and improve the working of joints masticatory muscles (Nigam and Nigam, 2010).
On the other hand, Wolf, Milton, Reiss and et.al., 2012 has asserted that “the most
important effectiveness of BTX-A at the time of treatment of temporomandibular joint disorder
is it increases the blood flow to the muscle and release of never fibers” (Wolf, Milton, Reiss and
et.al., 2012). The following toxin brings the reduction in muscle tone pain because of the
occurrence of myofascial pain syndrome. This enhances the blood circulation in the painful area

and releases some kind of nerve fibers in that area that compressed by abnormally contracting
muscle. It shows some instant effect in terms of direct liberate of endogenous endorphins from
the inserting the needle of injection. BTX-A brings a modification in the sense of balance of
peripheral and central neurotransmitters (Kim. H., Yun, P. and Kim, Y., 2016).
From the investigation of Fortuna, Vaz and et.al., 2011, it has found that “BTX-A is
effective in reducing muscle spasticity over the large area as compare to cover by the injection”
(Fortuna, Vaz and et.al., 2011). The following observation can be explained by the facts that Ach
is released by both gamma and alpha motor neurons. These both have involved in the muscle
contractions in terms of either voluntary or involuntary basis. Gamma motor neurons innervate
the intrafusal fibers of the muscle spindles. BTX-A causes atrophy of the intrafusal fibers and
extrafusal fibers where alpha motor neurons are situated. The following toxin satisfies the output
from the muscle spindle to the central nervous system. In addition to this, Sahai, Dowson, Khan
and et.al., 2010 has explored from their research that “BTX-A reduces the spindle afferent
discharge in the human jaw muscle spindle” (Sahai, Dowson, Khan and et.al., 2010). It has
brought the reduction of overall muscles contraction at the time of movement of jaws. Along
with this, it has reduced the excess muscle contractions that are responsible for the pain.

REFERENCES
Books and Journals
Bohluli, B., Motamedi, M.H.K. and et.al., 2011. Use of botulinum toxin A for drug-refractory
trigeminal neuralgia: preliminary report. Oral Surgery, Oral Medicine, Oral Pathology,
Oral Radiology, and Endodontology. 111(1). pp.47-50.
Coumou, H.C. and Meijman, F.J., 2006. How do primary care physicians seek answers to
clinical questions? A literature review IRP. Journal of the Medical Library
Association. 94(1). p.55.
Ernberg, M., Hedenberg-Magnusson, B., List, T. and Svensson, P., 2011. Efficacy of botulinum
toxin type A for treatment of persistent myofascial TMD pain: a randomized, controlled,
double-blind multicenter study. Pain.152(9). pp.1988-1996.
Fortuna, R., Vaz, M.A. and et.al., 2011. Changes in contractile properties of muscles receiving
repeat injections of botulinum toxin (Botox). Journal of biomechanics. 44(1). pp.39-44.
Kerscher, M., Roll, S., Becker, A. and Wigger-Alberti, W., 2012. Comparison of the spread of
three botulinum toxin type A preparations. Archives of dermatological research. 304(2).
pp.155-161.
Kim. H., Yun, P. and Kim, Y., 2016. A clinical evaluation of botulinum toxin-A injections in the
temporomandibular disorder treatment. SpringerOpen Journal. 30(8). pp. 1-5.
Nigam, P.K. and Nigam, A., 2010. Botulinum toxin. Indian journal of dermatology. 55(1). p.8 .
Riesenberg, L.A., Leisch, J. and Cunningham, J.M., 2010. Nursing handoffs: a systematic review
of the literature. AJN The American Journal of Nursing.110(4). pp.24-34.
Sahai, A., Dowson, C., Khan, M.S., Dasgupta, P. and GKT Botulinum Study Group, 2010.
Repeated injections of botulinum toxin-A for idiopathic detrusor
overactivity. Urology. 75(3). pp.552-558.
Schoels, M., Knevel, R. and et.al., 2010. Evidence for treating rheumatoid arthritis to target:
results of a systematic literature search. Annals of the rheumatic diseases, 69(4), pp.638-
643. Kable, A.K., Pich, J. and Maslin-Prothero, S.E., 2012. A structured approach to
documenting a search strategy for publication: A 12 step guideline for authors. Nurse
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Visser, K. and van der Heijde, D., 2008. Optimal dosage and route of administration of
methotrexate in rheumatoid arthritis: a systematic review of the literature. Annals of the
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Wolf, S.L., Milton, S.B., Reiss, A. and et.al., 2012. Further assessment to determine the additive
effect of botulinum toxin type A on an upper extremity exercise program to enhance
function among individuals with chronic stroke but extensor capability. Archives of
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Online
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through:<https://www.ebscohost.com/nursing/products/cinahl-databases/the-cinahl-
database>.[Accessed on 17th October 2016].
Medline. 2016. Online]. Available
through:<https://www.nlm.nih.gov/pubs/factsheets/medline.html>.[Accessed on 17th
October 2016].
PsycINFO. 2016. [Online]. Available through: <
http://www.apa.org/pubs/databases/psycinfo/index.aspx >. [Accessed on 17th October
2016].