Botox Forum: Research Review and Q&A

Welcome to our Botox forum, where we answer questions regarding botulinum toxin and review the research that’s come out over the past month or so. Today I have two papers and one question that came up. Let’s start with one of the research papers, and then we’ll get to the questions.

Treating Bruxism with Botulinum Toxin

Treating bruxism, as you know, sits in the sweet spot where you have a stack of research supporting the use of botulinum toxin to treat both the condition and the associated headaches, but it’s not yet covered by insurance. That’s a great position to be in—you can still accept insurance for other things, but take cash when you do this.

It’s also one of the safest and easiest procedures to learn. If you go to our membership site (which you have access to if you’re watching this) and look at my demonstration of how to treat it, you’ll see something similar to what’s described here. I think they complicate it a bit, but what this study provides—which hasn’t been done well until now—is EMG studies showing that it actually works.

They draw a nice diagram defining the safe area: you draw a line from the corner of the mouth to the earlobe, then palpate the masseter muscle. It’s very easy to do. The safe space is defined as the area inferior to that line, with the inferior border being the inferior border of the masseter muscle, level with the posterior border of the masseter muscle, and one centimeter posterior to the anterior border of the masseter muscle. So if you consider the masseter muscle as a square, then one centimeter away from the mouth puts you into the safe zone.

A simple way to do this is just to palpate the muscle. They performed four injections per side. The way I do it—which works great for headaches—is to simply palpate the muscle and place one injection right in the center. The dosing and the technique I use for finding that spot are covered in our course, but it still hits the target. They just use a more elaborate method of locating the target and place four injections instead of one.

For hypertrophy—when you’re treating, say, an Asian woman, which often happens with bruxism, but sometimes occurs without bruxism when someone simply wants a more feminine contour with accentuation of the cheek (since emphasis of the masseter muscle can be masculinizing)—this usually requires fifty units per side in an Asian woman, so a whole bottle of one hundred units of cosmetic botulinum toxin. In that case, I do three injections at different depths, and I teach you how to do that in the course.

Dr. Runels Botulinum Blastoff Course<-

The point I’m making is that for bruxism, you now have another study supporting it. This article is open source, so you can include the link in an email and say, “Here’s research showing that this works. We treat it.” I’ll put the link in the transcription.

One more nuance: for some reason, still only about half of the states in the US allow dentists to perform Botox injections. So you would be helping someone who may have only been offered a contraption to wear at night.

Question: Increasing the Botulinum Toxin Dose for Erectile Dysfunction

The question I received was: when injecting botulinum toxin for erectile dysfunction with a hundred units, is it okay to bump it up to two hundred?

Absolutely. If you look at the LD50 for botulinum toxin, we’re routinely using two hundred to three hundred units for migraines every three months, so this remains well within a safe range. The Xeomin company conducted a study showing that even at 100 units, many men still had active results at 9 months out. So whether you’re treating ED or treating a retracting penis where the man simply wants it to be more visible in the flaccid state, a hundred units is really a starting point—you can go up to two hundred or three hundred.

Along those same lines, for our Clitoxin procedure, my wife and I did the original study with fifty units. But that was based more on the fact that it just hadn’t been done before, and we were being very conservative. If you accept our postulate that the mechanism of action is not relaxation of smooth muscle, but rather modulation of the autonomic nervous system, then the mass of the clitoris in relation to the mass of the penis is irrelevant—because you’re using both as a port to facilitate axonal transport to the ganglion (in the case of the woman, lining the vaginal wall) to communicate with the midbrain.

In that case, the dosage would not vary just because the clitoris happens to be smaller than the penis. Perhaps we should be using 100 to 200–300 units in women in the same way. We’ve routinely bumped it up to 100 units, but we haven’t done the study yet, so we don’t know for certain. Anecdotally, however, it seems to be working perhaps better than the 50-unit dose. All of that is explained on our Clitoxin website.

The main point I want to stress here is that it’s acceptable to increase the penile injection up to 200 to 300 units.

Final Study: Music and Pain During Botulinum Toxin Injections

The last study asked: Does white noise or music relieve pain caused by botulinum toxin injections? Their conclusion is that they do.

This was reassuring to me, because if you’ve done my hands-on training, you know I have an album I’ve played over and over again—one I consider the most relaxing album ever made. The artist passed away about a year ago. I share the album in the course and mention that I’ve played it almost without exception every time I’ve injected cosmetic botulinum toxin. When I do parties, I’ll often just pull it up on my phone and play it, even if I’m not in my office. But in my office, it’s almost always playing, and I’m conditioned like Pavlov’s dogs—when it plays, I relax. I’m less rushed, and I think my patients have the same reaction.

I’ve mentioned that I studied while listening to it throughout medical school, and another physician who was training with me one day—a prominent gynecologist out in Texas—said he had listened to the same album all the way through medical school. I don’t think that’s coincidental. I think it’s magical.

If you pull it up, it’s George Winston’s December album. Play that while you’re injecting botulinum toxin. No one’s sure exactly why it works or what it’s triggering in the brain, but music helps, and that’s what I choose every day.

I hope that’s helpful. Have a great day.

Next hands-on workshops with live models<-

Online Botulinum Injection Course (including 4 medical indications)

Hardback textbook (414 pages)