Botox in Dentistry
Botox in Dentistry
Botox in Dentistry
66]
Review Article
Key words: Botulinum toxin A, bruxism, gummy smile, temporomandibular joint disorders
Introduction
Botulism is a lifethreatening disease first described by
Kerner.[1] It is caused by botulinum toxin(BT) also known
as botulinum neurotoxin produced under anaerobic
conditions by Clostridium Botulinum. Botulinum is one of
the most lethal toxins known and has found applications
in bioterrorism as well.[2] However, botulinum toxin is a
doubleedged sword. Botulinum is the first toxin to be
accepted for therapeutic uses. Since the first therapeutic
use by Scott for strabismus[3] till today, the spectrum of
therapeutic applications of BTs has widened. BTs can be
differentiated into seven types from A toG. However,
commercially available variants are purified exotoxin
and only BT typeA(BTA) and BT typeB(BTB) are
marketed by various brand names.
DOI:
10.4103/0975-5950.183860
Mechanism of Action
BT produces a transient dosedependent weakening
of muscle activity.[4] It is a neurotoxin and produces
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2015 National Journal of Maxillofacial Surgery | Published by Wolters Kluwer - Medknow | 152
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Srivastava, etal.: Botulinum toxin in dentistry
Preparation
Doses of BT used for the treatment of a particular
condition depend on the particular brand/preparation
as the unit of one product is not the same as the other.
Instances of botulism have been reported in patients
treated with intramuscular injections at therapeutic
doses.[5,6] However, BTA has been in clinical use since
1967 now, and its safety has been well established.
The two most commonly available types of BTA are Botox
and Dysport. About 2025 units of Botox are equipotent
to 80 units of Dysport. Botox is marketed as singleuse,
sterile 100 Units or 200 Units vacuumdried powder for
reconstitution only with sterile, preservativefree 0.9%
sodium chloride injection USP prior to injection.[7] It is
recommended that the reconstitution should be gentle as
froth arising out of vigorous shaking can lead to surface
denaturation of the toxin.
BT is stored in a frozen vial(24C) until it is ready
to use. Adding 4ml of 0.9% preservativefree normal
saline solution makes injections, and the preparation
should be used within 4h.[8] It is dispensed in small
vials containing 100 U or 500 U. The preferred syringe
is a calibrated 1.0mL tuberculin syringe with a gauge
preference of 2630.[9,10]
Facial wrinkles
BTA has been most widely accepted for its use to
temporarily treat hyperfunctional facial lines
Forehead rhytids are managed by injecting 1020 U of
BTA injected at least 1cm above the orbital rim with
a general rule of avoiding injecting frontalis without
injecting glabella to reduce the chances of brow
ptosis. The injection site and pattern of injections
vary depending on the desired brow position. It is
preferred to inject lower doses away from the brow
so as to avoid the frozen look
Glabellar lines(frown lines) are generally managed
by 2040 U of BTA divided over five injection sites.
The five injection sites correspond to the area of the
procerus(between the eyebrows above the nasal
bridge), paired injection sites that correspond to
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Srivastava, etal.: Botulinum toxin in dentistry
Temporomandibular disorders
Temporomandibular joint disorders(TMD) is a term
suggested by Bell[30] and signifies not only disorders of
the temporomandibular joint(TMJ) but also includes a
spectrum of disturbances associated with the function
of masticatory system, which are poorly understood and
often intermingled with other chronic pain disorders.
These set of disturbances have been previously
termed as TMJ dysfunction syndrome, functional TMJ
disturbances, myofascial pain dysfunction syndrome,
and temporomandibular pain dysfunction syndrome.[31]
TMDs may be myofascial(those related to muscles
themselves) or arthrogenic(those related to TMJ), but
majority of TMDs include a myogenic component[10,32]
and muscular spasticity in relation to bruxism, external
stressors, OMD, and psychomotor behaviors. [33]
Conventional treatment approaches for TMDs include
physiotherapy and exercise, antiinflammatory and
analgesic drugs, muscle relaxants, oral appliances
(mostly stabilization splints), or a combination of these
modalities. Surgery is sometimes indicated but is an
expensive and invasive treatment option. BTA has been
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Srivastava, etal.: Botulinum toxin in dentistry
Bruxism
Severe clenching or grinding of teeth is called bruxism
and is often associated with generalized attrition, TMJ
symptoms, headache, and muscular pain. BTA has
been successfully used in cases of bruxism.[41] Injection
of BTA bilaterally into masseter muscles(in a dose
range of 25100 MU per side) has been documented
to significantly reduce the severity of symptoms for
678weeks(mean 1917weeks).[41] In comparison with
oral splint, BTs are equally effective on bruxism and
injections at a dosage of<100 U are safe for otherwise
healthy patients.[42] Use of BTA in sleep bruxism is also
encouraging,[43] and a single injection has been shown to
be effective for at least a month.[44]
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Srivastava, etal.: Botulinum toxin in dentistry
General Guidelines
Preparation has to be used within 4 h
The area of the injection has to be covered with a
topical anesthetic cream or can be anesthetized using
ice
Start with a lower dose
Muscles should not be paralyzed completely
Males generally require higher dose due to larger
muscle masses.
Adverse Effects
In general, adverse reactions are uncommon and
localized. The results from a systematic review with
metaanalysis have concluded that BTXA has favorable
safety across wide spectrum of therapeutic uses. [74]
Botox is administered by injection and dosing depends
on the condition that it is used for. Side effects of Botox
include allergic reactions, rash, itching, headache, neck
or back pain, muscle stiffness, difficulty in swallowing,
and shortness of breath. This can also be accompanied by
nausea, diarrhea, stomach pain, loss of appetite, injection
site reactions, sore throat, runny nose, ringing in ears, and
increased sweating in areas other than the underarms.[75,76]
The two most common medicationrelated side effects
from BT orofacial injections are alterations in salivary
consistency and inadvertent weakness of the swallowing,
speech, and facial muscles. These complications are
injection sitespecific(e.g.,more common with lateral
pterygoid injections and palatal and tongue muscle
injections) and dosedependent problems.
In some cases, BT effects may be observed at sites beyond
the site of local application, known as the Spread of
toxin effect. The symptoms of such a presentation are
consistent with the actions of BT and include generalized
muscle weakness manifesting as diplopia, dysphagia,
dysphonia, ptosis, and urinary incontinence or even
breathing difficulties. The probability of this spread of
toxin effect is even more in the face as well as head and
neck region due to facial planes and spaces.
BT is classified as category C for use in pregnancy, and its
use is warranted only if the potential benefit outweighs
the potential risk to the fetus. Similarly, use in nursing
mothers is also not recommended routinely. Use of BT
in pediatric age groups should also be restrained, and
FDA guidelines for its use were followed.
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Srivastava, etal.: Botulinum toxin in dentistry
Contraindications
In any known hypersensitive reaction to any of the
botulinum preparations
Allergy to any of the constituents of BTXA or BTXB[9]
Presence of active infection at the proposed injection
site[78]
Pregnancy and lactation[77]
Patients receiving treatment with aminoglycosides,
anticholinergic drugs or other agents interfering with
neuromuscular transmission or muscle relaxants
should be observed closely because the effect of
Botox may be potentiated
Patients suffering from peripheral motor neuropathic
diseases, sclerosis, or any neuromuscular junction
disorders like myasthenia gravis are at increased risk
for clinically significant adverse reactions and should
be closely monitored
Psychologically unstable patients.[9]
References
1.
2.
3.
4.
5.
6.
7.
Future Perspective
Although plenty of reports on the use of botulinum in
maxillofacial region are published, quality literature
is scarce.[22,7981] Most of the published reports are case
reports of series and actual randomized control trials
are lacking. While dental surgeons are well placed by
their virtue of knowledge of facial anatomy, further
skill enhancement training is warranted to prepare
them to administer botulinum toxin for therapeutic
uses. Many regulatory bodies in the United States have
already started additional licensure procedures for
practicing Botox in dentistry. The interest among dental
practitioners to practice botulinum is growing, mostly
for esthetic dental reason; however, a majority still reject
the idea due to lack of knowledge and experience.[82]
Conclusion
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
[Downloaded free from http://www.njms.in on Friday, July 15, 2016, IP: 14.139.236.66]
Srivastava, etal.: Botulinum toxin in dentistry
21. Bentsianov B, Francis A, Blitzer A. Botulinum toxin treatment of
temporomandibular disorders, masseteric hypertrophy, and cosmetic
masseter reduction. Oper Tech Otolaryngol Head Neck Surg 2004;15:1103.
22. IhdeSK, KonstantinovicVS. The therapeutic use of botulinum toxin in
cervical and maxillofacial conditions: An evidencebased review. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:e111.
23. Jaspers GW, Pijpe J, Jansma J. The use of botulinum toxin type A in
cosmetic facial procedures. Int J Oral Maxillofac Surg 2011;40:12733.
24. AminV, AminV, SwathiD, Ali JabirD, ShettyP. Enhancing the smile
with botoxCase report. Glob J Med Res 2014;13:15-8.
25. TezelA, FredricksonGH. The science of hyaluronic acid dermal fillers.
JCosmet Laser Ther 2008;10:3542.
26. HwangWS, HurMS, HuKS, SongWC, KohKS, BaikHS, etal. Surface
anatomy of the lip elevator muscles for the treatment of gummy smile
using botulinum toxin. Angle Orthod 2009;79:707.
27. Polo M. Botulinum toxin type A (Botox) for the neuromuscular
correction of excessive gingival display on smiling(gummy smile). Am
J Orthod Dentofacial Orthop 2008;133:195203.
28. Miskinyar SA. A new method for correcting a gummy smile. Plast
Reconstr Surg 1983;72:397400.
29. Choi YJ, Kim JS, Gil YC, Phetudom T, Kim HJ, Tansatit T, et al.
Anatomical considerations regarding the location and boundary of the
depressor anguli oris muscle with reference to botulinum toxin injection.
Plast Reconstr Surg 2014;134:91721.
30. Bell WE. Clinical Management of Temporomandibular Disorders.
Chicago: Year Book Medical Publishers; 1982.
31. Okeson JP. Management of Temporomandibular Disorders and
Occlusion. Missouri: Elsevier Health Sciences; 2014.
32. FreundBJ, SchwartzM. Relief of tensiontype headache symptoms in
subjects with temporomandibular disorders treated with botulinum
toxinA. Headache 2002;42:10337.
33. Kaplan AS, Assael LA. editors. Temporomandibular disorders: Diagnosis
and treatment. Philadelphia: WB Saunders Company; 1991. p 40-9.
34. FreundB, SchwartzM, SymingtonJM. The use of botulinum toxin for
the treatment of temporomandibular disorders: Preliminary findings.
JOral Maxillofac Surg 1999;57:91620.
35. LeeKM, ChowJ, HuiE, LiW. Botulinum toxin typeA injection for the
management of myofascial temporomandibular pain disorder. Asian J
Oral Maxillofac Surg 2005;17:1003.
36. SchwartzM, FreundB. Treatment of temporomandibular disorders with
botulinum toxin. Clin J Pain 2002;186Suppl:S198203.
37. SongPC, SchwartzJ, BlitzerA. The emerging role of botulinum toxin in
the treatment of temporomandibular disorders. Oral Dis 2007;13:25360.
38. MooreAP, WoodGD. Medical treatment of recurrent temporomandibular
joint dislocation using botulinum toxin A. Br Dent J 1997;183:4157.
39. DaelenB, ThorwirthV, KochA. Treatment of recurrent dislocation of
the temporomandibular joint with typeA botulinum toxin. Int J Oral
Maxillofac Surg 1997;26:45860.
40. FuKY, ChenHM, SunZP, ZhangZK, MaXC. Longterm efficacy of
botulinum toxin typeA for the treatment of habitual dislocation of the
temporomandibular joint. Br J Oral Maxillofac Surg 2010;48:2814.
41. TanEK, JankovicJ. Treating severe bruxism with botulinum toxin. JAm
Dent Assoc 2000;131:2116.
42. LongH, LiaoZ, WangY, LiaoL, LaiW. Efficacy of botulinum toxins on
bruxism: An evidencebased review. Int Dent J 2012;62:15.
43. Lee SJ, McCall WD Jr., Kim YK, Chung SC, Chung JW. Effect of
botulinum toxin injection on nocturnal bruxism: A randomized
controlled trial. Am J Phys Med Rehabil 2010;89:1623.
44. ShimYJ, LeeMK, KatoT, ParkHU, HeoK, KimST. Effects of botulinum
toxin on jaw motor events during sleep in sleep bruxism patients: A
polysomnographic evaluation. JClin Sleep Med 2014;10:2918.
45. Xu H, Shan XF, Cong X, Yang NY, Wu LL, Yu GY, et al. Pre and
postsynaptic effects of botulinum toxin A on submandibular glands.
JDent Res 2015;94:145462.
[Downloaded free from http://www.njms.in on Friday, July 15, 2016, IP: 14.139.236.66]
Srivastava, etal.: Botulinum toxin in dentistry
69. Grnheid T, LangenbachGE, KorfageJA, ZentnerA, van EijdenTM.
The adaptive response of jaw muscles to varying functional demands.
Eur J Orthod 2009;31:596612.
70. Kato T, Thie NM, Montplaisir JY, Lavigne GJ. Bruxism and orofacial
movements during sleep. Dent Clin North Am 2001;45:65784.
71. Mazzuco R, Hexsel D. Gummy smile and botulinum toxin: A new
approach based on the gingival exposure area. J Am Acad Dermatol
2010;63:104251.
72. PoulainB, PopoffMR, Molg J. How do the botulinum neurotoxins block
neurotransmitter release: From botulism to the molecular mechanism
of action. Botulinum J 2008;1:1487.
73. MajidOW. Clinical use of botulinum toxins in oral and maxillofacial
surgery. Int J Oral Maxillofac Surg 2010;39:197207.
74. NaumannM, JankovicJ. Safety of botulinum toxin typeA: A systematic
review and metaanalysis. Curr Med Res Opin 2004;20:98190.
75. US Food and Drug Administration. Information for healthcare
professionals: OnabotulinumtoxinA (marketed as Botox/Botox
Cosmetic), AbobotulinumtoxinA (marketed as Dysport) and
RimabotulinumtoxinB (marketed as Myobloc). FDA Alert. Rockville,
MD: FDA. 2009 Aug.