BOTOX Neurotoxin to Masseter Muscle Demo – Transcription
- SHATKIN: So that — because this is part of the consultation. So the patient comes to your office. She’s going to give you the history and then we’re going to —
- THARP: Tell me about your problems. Tell me what you’re going on, what’s going on.
MARLEY: Well, recently I’ve grinded my teeth at night.
MARLEY: Every morning I wake up and I just am so sore for the rest of the day.
- THARP: Point to where you’re sore.
MARLEY: Basically all in here.
- THARP: Right in there. Do you have any clicking or popping in your jaw joints?
MARLEY: Yeah, my jaw.
- SHATKIN: Jaw cracks. And when you wake up in the morning, it seems better. But by the end of the day, it’s problematic, or is it you wake up in the morning with a sore jaw?
MARLEY: I wake up with a sore jaw.
- THARP: Did you have any history of ever falling down and hitting your chin? Do you remember that at all?
MARLEY: I don’t believe so.
- THARP: That’s good. Do you notice any difference of when you’re under stress or tension and when you’re not under stress or tension?
MARLEY: Yeah, when I’m under stress I clench up a lot.
- THARP: So Dr. Dawson likes to see that when you’re doing a corroboration, it’s not always because you hate your mother. Anyhow, let me get the other girl on here and then we’ll see if we can do a quick exam to see how sore your muscles are.
- SHATKIN: So your history is pretty typical of what a TMJ patient has had. Have you had some therapies done up until now to help this?
MARLEY: No. But recently I have gone to a speech therapist because I have broken modules, and she’s noticed that it’s all combined with the tenseness with my jaw and throat.
- SHATKIN: Right.
MARLEY: And she’s worked on trying to just relieve some stress. She did the thing with the pinky up in the back molar.
- SHATKIN: And she felt that —
- THARP: Did she find out that your lateral pterygoid was hot?
- SHATKIN: You had some pain there?
THARP: Good. Now when we do that exam, I want you to watch her eyes. Because even if the patient doesn’t say they’re having pain, when you get to the point where you’re touching a hot muscle, the eyes automatically cringe just a little bit.
- SHATKIN: And one last question before he exams you. Have you ever had a night guard or anything you wear to prevent the grinding at night?
MARLEY: Yeah, I’ve tried a small cap made by a dentist that goes on my bottom teeth, but it was just too uncomfortable. And then with other mouth guards, I’m too much of a light sleeper for it to — with me to fall asleep.
- SHATKIN: Would you find it that it would pop out of your mouth at the middle of the night and wake up on the pillow?
MARLEY: Yeah, it was too uncomfortable.
- SHATKIN: So you were pushing it out on your own. Ok, I’m going to step aside and let Dr. Therapa do your exam.
- THARP: Yeah, we’ll do the —
- SHATKIN: Can you zoom in there, Dave, maybe get a better view?
- THARP: First thing I’m going to do is just do a palpation exam of the joints. Everybody knows they’re right in front of the tragus. Go ahead and open, close. Open, close. Now do you feel any clicking at this point?
MARLEY: Yeah, in my left side.
- THARP: Without — normally I would do this with a doppler. Does anybody have a doppler in this room? Have you ever used one? They’re really quite fun and easy. It’s the same —
- SHATKIN: Let’s see if we can get it.
- THARP: Yeah, you might be able to hear it. Open. Not hearing it.
- SHATKIN: Those are high heels in the back of the room
- SHATKIN: Not really significant.
- THARP: And good, she’s brought me a tongue compressor. This is something that I always teach every young dentist that I’ve gotten. Centric relation is, you would think, very hard for a patient to get into, and it isn’t. A patient can — you can put a patient themselves into centric relation. You take a flat surface like a tongue compressor, or what I like to use is my mouth mirror. Put it right between their center of their teeth, close. Ok now slide your lower jaw forward and back. Forward, back. Now do you feel any clicking, by the way, when we do that? It should be the same type of clicking when you do it open and close.
- THARP: Now when you go all the way to the back, she’s going to be in centric relation, or if she has a damaged joint because of the clicking. She’ll be what we call adapted centric posture. Now, lighten up that state all the way in that back position, and she’s already in centric right there. Now, what you do to teach a patient that there might be something wrong with their bite, go ahead and stay in that back position, all the way in the back. Not forward, go to the back again. You can watch them smile at me and do that. Just smile.
- SHATKIN: Don’t choke
- THARP: There you go. So she’s in centric right there, or darn close to it. Now, lighten up just as light as can be. I’m going to slide the tongue compressor out. And I want you to close straight up feather-like and tell me if you hit any of your teeth first, ok? Close feather-like straight up. Did you hit any one tooth first?
- THARP: Point to it. Right there, and it’s usually in the first bi-area. That’s the most common. Most people think it’s the second molars, but that’s the most common interference for when you’re doing that kind of corroboration. So she just learned there’s something wrong with her bite that might be making her want to grind her teeth more. Let me do one more demonstration. We’re going to try that same thing. Tilt your head way there. Let me cradle your head. Thumbs on a chin. Second and third fingers way in the back at the corner of the mandible. And I’m just going to give you open and close with me, feather-like. Let me just see if we can get that at the same spot. And I’m pushing mainly up with the back. And now it’s started to come together until you barely touch. Did you hit the same spot?
THARP: That’s the confirmation that she has an interference that maybe want her to grind more. So now, take your little finger. Go right up past the second molars and watch her eyes. Shift your jaw to the left a little bit. A little — that’s it, good. See, you see them blink? Does that hurt?
- THARP: Now do the same thing on the other side. Shift your jaw to the left, other left. Your right, rather. Your right — there we go, good. And the right side now will hurt just a little bit, but not as bad, right?
- THARP: So she’s got — she’s got a hot lateral pterygoid. And if we had a doppler, we could confirm that she has an opening click that is reciprocal — that the disc actually is clicking. Once you open the clicking back onto the head of the condyle, clicking back off once she comes back to adapted centric posture. It’s no longer centric relation once you have a damaged joint. What we want to do — you can also palpate the temporalis, the lateral pterygoid, the internal pterygoid — I’m sorry, not [inaudible 6:52] pterygoid, the masseters. But usually you don’t get painful muscles except the lateral pterygoid. Anything there?
- THARP: A little bit right there? So she’s even sore in her masseters. That means she’s really gnashing. It’s [difficult 7:09].
- THARP: So I’m looking forward to helping you. You may not get it until a week from now, but you’ll notice a big difference in how your pain level is. Do you get headaches? THARP: Point to where you get the headaches at. Right here?
MARLEY: Yeah, more in the forehead.
- THARP: Right there. Yeah, it almost always comes right at the —
- SHATKIN: The tension.
- THARP: Interior part of the temporalis. Sometimes you get it here, sometimes you get it in the back.
MARLEY: Yeah. It goes randomly.
- SHATKIN: That was good. Alright, so why don’t you take her through the marketing process or do you want me to do the marketing process?
- THARP: You do the marketing process.
- SHATKIN: I’m going to give you this microphone back and grab some — there you go.
- THARP: I’ll just take it.
- SHATKIN: And then I’m going to get — this is how I do it. I let the dentist do the diagnostic part of it, and then I’ll come in and if they’re referred from my dental practice here or somewhere else. Actually, the reason I had a patient that came in from Maryland to have the injections done, actually a dentist sent her to me because he knew that I did this. And she flew down in the morning and flew back in the afternoon. So we’re going to —
NURSE ACKERMAN: Are you going to mark her first?
- SHATKIN: Yeah, I’ll mark her. I’m going to let Kathy dilute this for us so she can get it ready. And we’re going to show you the dilution later. So basically, it’s really pretty simple. Just like we did on our styrofoam dummies. I’m going to have her bite down and I’m feeling the anterior border of the masseter [8:38] right here. It’s obvious. It’s hard to miss. Relax. When they’re relaxed, you can still feel it on here. But many times, you can’t. So bite that down again. So I’m just going to mark the anterior border right there with my marking pen. Now, relax. Now I’m going to mark the back. Sorry, go ahead and bite again. Right here. The only other anatomic area — you can relax now — is the inferior border of the mandible near the angle. The mandible is right here. So I want to be up in this area. I don’t want to be up too high. The protygland is back in here. So part of the product is overlined in the masseter muscle. So we’re going to pretend that we don’t want the product injected, although sometimes we’ll put Botox in the product. But it doesn’t make any sense to do that. So we’ll try to stay a little bit more if we go to divide this in half. We’re going to go a little bit more on the anterior side of it. But either way, you’re going to [inaudible 9:32] with the bulk of the muscle. A lot of instructors suggest you want to avoid piercing the protygland. I don’t think it’s a big problem unless you hit one of the ducts or some major duct there where you could get salivary cyst or some drainage. You wouldn’t want to do that. So that’s why for our purposes, we’re going to stay a little bit more towards the anterior surface of it.
So Ms. [9:55], go ahead and clench again. I can see your muscle balls. Her bulkiest part of the muscle is right here. I’m going to put one dot there, and then we’ll just go a little bit below that, perhaps. And I’ve got my two spots there that I’m going to inject. So now I’m going to do the same thing on the other side so the people on this side can see. So go ahead and bite down. I’m feeling the border there. Remember what I said: the facial artery is coming about a centimeter right across here, so we want to stay away from that. Bite down again. I’m going to mark the posterior aspect right there. And then bite down real hard. So she’s got — this side is a little bit different. The bulk is more right here. And then I’m going to do it just another section there. So they don’t have to be exactly symmetrical because as Dr. Tharp pointed out, she’s got more left lateral pterygoid problem than she has on the right side. So that could be why the masseter is a little bit different shape there. But these are my two marks. Now if you want to be safe, when you’re drawing this like we did on our facial skull there. Draw a line there so you’re not actually hitting the dots where I marked in there, because that would be a big mistake. You don’t want to do that.
So what Kathy did was she — did you reconstitute it yet?
NURSE ACKERMAN: Not yet. I just wanted to show up because not everybody — well we’re going to have people reconstituting, but not everybody will get a [freeze-dried 11:07].
- SHATKIN: Let’s go over this. Thank you, Kathy. So she drew out of the bacteriostatic saline, which is buffered saline, which would give you a little bit of up to one week or ten days of use of the Botox. She drew up 1cc and a little bit more. I recommend using 1cc syringes because if you’re using three and you’re off slightly, it will just change the concentration. So if you use one, it’s a little bit more exact. So a little bit more than 1cc, you’re going to push it up until you get exactly to the one. You can’t see from where you are, but you will when you’re up close. And then she popped off the outer cap. It’s sterile inside, so you don’t have to cleanse it with alcohol. It’s still sterile. And then you’re just going to take this and push it right in. It’s freeze-dried, which is interesting. The bottom — the very first Botox I got, I thought there was nothing in there. I knew you had to reconstitute, but I’m looking at it and saying, I don’t think there’s anything in there. But then I called up the company, and they said, yeah, they said there’s something in there. It’s basically freeze-dries in the bottom of the bottle, and that’s the difference between this and Xeomin. Xeomin coats the total lining of the bottle and you have to agitate it a little bit differently. But with this Botox, you just put the needle through here. It’ll draw it in. You see it draw right in because it’s in the vacuum. You don’t want to force it in. You don’t want to agitate it. You don’t want to shake it. You just want to put it in like that, and then what I usually do is I just do this on the table, or you can spin it like this. Sometimes they recommend just rotating it like this, but in a gentle, comfortable way. We’re going to have some bottles for you to practice on later. So then what we do is we take that out, and I like to take the cap off. Problem is if you stick a needle through this now, as you’re going to clean it with alcohol, it’s going to dull the needle. And I got a picture of that on the next talk, which we’re going to do after lunch.
So we’re going to pop this off. You can use actually a can opener, but we use the scissors because we got them in the office. You just pop them off, and you leave the rubber cap there. If it comes loose, you can always take it off later. So there, I took the cap off. Here’s our rubber cap. So the [substance 13:09] that goes back on. There’s our solution. Now there’s different ways to draw it up, and every time you stick that needle into something that’s glass, it’s going to dull the tip. I usually do no more than five injections through the skin with one needle. Now because she’s got a — because the masseter’s a deeper muscle, we’re going to use our 1cc syringe. And we’re going to use the half-inch needle like I mentioned before. And I just happened to have a 30 gauge. [inaudible 13:35] I’m going to use a 30 gauge needle, a little more comfortable, but it’s half-inch. This is like, I think, 3/8ths of an inch, so it goes a little bit deeper. So we got the 1cc syringe and what we’re going to do is we’re going to draw up the Botox equivalent to that amount. So we put 1cc in there. So that’s every 10th of a cc is 10 units. Because you have 10/10ths is a full. So every 10th is 1cc, so I’m going to make sure that needle is [squished 14:06] down properly. It should fit the syringe easily, and we’re going to put it in there. And since I want five units in two spots, that’s 10 units total, I’m going to drop one-tenth of a cc. Pretty easy, right? I try not to let the needle touch down at the bottom too much. If it does touch a little bit, it’s ok, but very lightly. And then I’m going to draw it up. Now what did I do wrong? I didn’t push the air out first. Put it back in there. Remember I told you, we got to push out the air like we showed you earlier, and then we’re going to put that in there and draw it up to 1/10th. 1/10th cc, there we go. No, I’m going to do it — well, we’ll do it twice. I’ll do it two times. We’ll draw it two times so we do both sides. Sometimes you get a little bubble there. So draw it up until the line we want to put in, 2/10ths. So we do half on each side. So I cleanse the skin with it. I’ve already got it marked, I cleanse the skin, a little tissue.
MAN 1: Each tenth you used ten units.
- SHATKIN: Right. The way to do five and five, on one side, five, and five on the other side.
MAN 2: So what’s the saline for? I lost you.
- SHATKIN: We reconstituted it because it comes freeze-dried in the bottle. So we mix it in there to reconstitute it. That’s all the saline we put in there. No more saline.
MAN 2: How much saline are you putting into one bottle?
NURSE ACKERMAN: 1/16th.
- SHATKIN: We put 1mL, 1cc. That takes 100 units for 1cc.
MAN 2: So one to one. We’re diluting it in half.
- SHATKIN: 1cc. Well no, not half. It’s dry to start with. There’s nothing in there, no liquid in there.
MAN 2: Oh, you’re just making it.
- SHATKIN: Yeah, we’re just making it. That’s the recap. We’re going to do some more of that later, but we got the demonstration gals here, so we want to do it now. So I just cleanse the skin and sometimes patients walk out of the office with the tissue underneath their shirt here because — yeah?
AUDIENCE: Can you turn her towards this way?
- SHATKIN: Yeah, let me turn her this way. Now everybody can see. Then I’ll stand on this side, maybe that will be better. Turn your head this way. So here’s my spots, clench down. I want 10 on each side, isn’t that what we decided, 10 on each side? So I’m going to put half of the 1/10th on one spot, all the way in. And half of the 1/10th in the other spot, keep clenching. And then that side’s done. I’ll do a little massage there just so it won’t drip. Now the other side, for the purpose of the people that are looking on the other side, clean it with some alcohol just to cleanse the skin. That’s all I have to do to clean it. Go ahead and clench down. The biggest, bulkiest spot of that —
- THARP: And you’re going all the way in with that needle.
- SHATKIN: The needle’s all the way in. And then that’s it. It’s a half-inch deep, but remember, your skin’s thickness affects it a little bit. And then that’s it. That wasn’t too bad, was it?