Tooth Pain Without Reason – Botulinum it

Continuous pain of tooth without obvious cause is called Atypical Odontalgia.  Up until now it has been poorly treated. Now injection of botulinum can achieve at least 50% reduction in pain. It requires injecting gums between affected teeth and areas of referral – including lips and palate if necessary.

J Pain Res. 2018 Aug 23;11:1583-1588. doi: 10.2147/JPR.S169701. eCollection 2018.
OnabotulinumtoxinA injections for atypical odontalgia: an open-label study on
nine patients.
García-Sáez R et al

  • Their theory involves peripheral sensitization  of periodontal nerve plexus
  • piloted 4 cases and went on to do 5 more = 9 cases
  • mean maximal pain was 8/10
  • all had “phantom pains” from missing teeth
  • Used Onabotulinumtoxin A (OnabotA)
  • 100 units in 2 mls  = 5 units/0.1ml
  • Using 30 gauge needle injected 0.05 ml = 2.5 u each site
  • Injected “dental alveoli of missing teeth” – ie the hole
  • Injected in interdental papilla gingiva :

papilla inject

Then inject several sites on gingival mucosa (maybe between other teeth sore etc

Then inject adjacent pain referring gum and palate areas

[most pics directly from article]gum inject.png

Injected up to 12 sites  = max dose 30 u – mean was 8 sites per patient – minimum 4 sites

repeat procedure q3 months

  • Over 50% relief with max pains 0-3/10
  • one all better, 4 intermittent pain, and rest mild continuous pain
  • duration effect 2-6 months

Comment – I have a case of occipital neuralgia I first inject with botulinum and the follow up  1-2 weeks later with semi-neurolytic 5% lidocaine injections. The  bolulinum renders nerves more sensitive to the semineurolytic effects. I Think they could have capitalized on the botulinum by following up with 5% lidocaine injections. Nonetheless, they have preformed a miracle for cases sometimes just tossed away as “nuts”.


New article discussing orofacial pains, some after dental implants, after facial nerve reconstruction, or just atypical orofacial pains – the former 2 did well with botulinum but not the latter.
Maxillofac Plast Reconstr Surg. 2018 Aug 6;40(1):21. doi:
10.1186/s40902-018-0159-z. eCollection 2018 Dec.
Treatment of non-odontogenic orofacial pain using botulinum toxin-A: a retrospective case series study.
Kim SY et al

  • describe atypical facial pain as diffuse pain deep in tissues without obvious cause ranging from dull, tingling, sharp or throbbing. Treatment is often unsatisfactory.
  • case 1 – upper lip and palate burning and throbbing – used 250 u Dysport into right upper anterior gingiva and repeated 3 month later with no pain thereafter
  • case 2 – intermittent severe pain after facial reconstruction – at 3 month intervals: 25 u Innotox into left face and left masseter; repeat left low lid and zygoma; 3rd into stylomastoid foramen – markedly reduced pain
  • Cases after dental implant surgery responded well BTX-A varied from 20 – 200 u a dose
  • 2 cases of atypical facial pains did NOT do well
  • transient facial asymmetry or unbalance occurred but was not a major problem.
  • Their conclusion was subjects that had pain from traumatic trigeminal neuralgias from dental implants or facial nerve damage – did well – more into gingiva vestibule and lip, masseter and temporalis
  • But  atypical facial pains did not respond

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