Bill Klaproth: This is OMS Voices, an AAOMS Podcast. I’m Bill Klaproth. With me is Dr. Vickas Agarwal. He is a board-certified oral and maxillofacial surgeon practicing in Richmond, Va., as we talk about relief from facial pain through injectables. Dr. Agarwal, welcome.

Vickas Agarwal (Guest): Thank you, Bill, for having me. I appreciate it.

Bill Klaproth: Yeah. Nice to see you. So, let’s talk about this. So, how do neuromodulators, such as Botox, work to alleviate facial pain and what types of facial pain conditions can it treat?

Vickas Agarwal (Guest): So, Botox, as you mentioned, is a neuromodulator, which means it works at the junction between a nerve and a muscle. What it does is it blocks those nerve signals to muscles, reducing tension and pain. We normally use it to treat TMJ disorder or TMD, myofascial pain, which is also known as just a muscular pain, chronic migraines and other neuropathic facial pain conditions.

Bill Klaproth: So then who would be an ideal candidate for injectable treatment for facial pain and how do you decide this, how is eligibility determined?

Vickas Agarwal (Guest): Well, Bill, so as with any chronic condition, we employ the least invasive methods first. So, we’ll try medications, home remedies, physical therapy, and if those fail, then we pursue further treatments such as Botox. And we have to find ideal candidates, those with chronic facial pain, they’re unresponsive to other treatment, and we go through a thorough evaluation process. That includes a patient history, thorough physical exam, in which we use to then come up with a diagnosis. Once that diagnosis is done, then we can administer Botox.

Bill Klaproth: So, you do a full evaluation first to determine if Botox is the correct method of treatment.

Vickas Agarwal (Guest): Yes, that’s correct, Bill.

Bill Klaproth: Got it. So, then what is the procedure for administering injectables such as Botox for facial pain and what should patients expect during and after the treatment?

Vickas Agarwal (Guest): Botox injection itself is normally a powder first. We dilute it according to the manufacturer’s instructions. We use the smallest needle possible to then inject it into the muscle through the face. So, what can patients expect? There may be a slight injection pain, although sometimes we can use topical anesthetics or cold packs, et cetera, to help distract the patient from the pain. And then you can expect some swelling, bruising, bleeding, very, typical signs of any injection although it’s very mild, for the most part.

Bill Klaproth: So, when it comes to facial pain, where are you generally injecting this? Where do people suffer facial pain the most?

Vickas Agarwal (Guest): There’s two ways to do it. Usually, patients may have we call trigger points, meaning there are certain areas of a muscle that cause them pain, or is there maybe their whole muscle that hurts. So, either I’ll identify those trigger points or cover the entire muscle itself to eliminate the pain in that area.

Bill Klaproth: So, would that be, someone chewing or smiling or anything involved with facial muscles, is that correct?

Vickas Agarwal (Guest): That’s correct, yes. Most often it’s from chewing or talking, or sometimes patients have them at rest without any activity.

Bill Klaproth: So that’s where you said earlier, Botox works between the nerves and the muscles, that’s where it comes in.

Vickas Agarwal (Guest): Yes, that’s correct. It prevents the nerve signal from conveying to muscle to help lessen or prevent contraction and reduce tension and pain.

Bill Klaproth: So then how long do the effects of injectables last for facial pain and what would be the typical treatment schedule?

Vickas Agarwal (Guest): Typically, patients will first notice some relief in about three days. The peak onset is around three weeks, and the results last for about three to six months. So, for me personally, I’ll have a patient follow up usually in about a month or so. I’ll kind of talk to him or her and say, “Hey, how are you feeling? Are you getting any relief from the Botox?” And if they are, then we’ll schedule them again about three to six months post injection for reinjection if they’re satisfied with the results.

Bill Klaproth: Then, someone can manage facial pain like this for a long period?

Vickas Agarwal (Guest): Yes, yes. Typically, most patients are on this for years at a time and in some patients, the pain just goes away and there’s no rhyme or reason why sometimes.

Bill Klaproth: Well, that’s really interesting. So, then what are the potential risks and side effects of using injectables for facial pain? How can those be managed?

Vickas Agarwal (Guest): Most patients don’t experience many symptoms at all, but the most common ones include bruising, swelling, some mild discomfort. Rare but serious risks include unintended muscle weakness allergic reactions, although that’s, again, very rare. The way we minimize and manage these side effects is by choosing a qualified practitioner, someone who’s experienced administering Botox, and you follow the post-treatment guidelines that your practitioner may give you.

Bill Klaproth: Right, so you mentioned finding somebody that’s qualified. We see ads all the time for Botox injections, billboards, magazines all over the place. So why choose an OMS for this?

Vickas Agarwal (Guest): Well, that’s an easy question. We are trained experts in the face, mouth and jaws. That’s all we do day in and day out. We have a comprehensive medical and dental education. And we have specialized training in facial esthetics, reconstructive surgery, and all of that includes Botox. So, in my opinion, we are the main people that should be doing this, especially for facial pain. And as set forth by our specialty, we have very high standards of care and precision in treatment.

Bill Klaproth: Dr. Agarwal, I want to thank you so much for your time today. Before we wrap up, is there anything else you want to add? Anything else we need to cover?

Vickas Agarwal (Guest): No, Bill, I think that’s it. I really appreciate the opportunity and thank you to everyone listening.

Bill Klaproth: Absolutely. Once again, that is Dr. Vickas Agarwal, and for more information and the full podcast library, please visit MyOMS.org. And if you found this podcast to be helpful, please share it on your social media and don’t forget to subscribe. Thanks for listening.