BOTOX THERAPY - EMERGING ROLE IN DENTISTRY

Subash L

    INTRODUCTION

    Dentistry were developing and updating day via day.   

    Botulinum toxin utilized in dentistry for the remedy situations, such as parafunctional clenching, extracapsular myogenic temporomandibular disorder, trismus, and the related complications, is a new alternative for symptom alleviation in sufferers in whom conventional treatments are not effective.   

    Aesthetic facial surgical treatment has been dominated by means of pores and skin tightening and tissue removal methods.   

    These facelift processes have been described initially as the elevation,tightening, and excision of pores and skin.     

    Botox remedy are became the game changer of minimum invasive beauty facial surgical procedure

    Photo credit: https://creativedentalcare.com/using-botox-dental-problems/ 


    Photo credit: https://m.indiamart.com/proddetail/botox-injection-18953743830.html



    HISTORY


    Photo credit:https://www.researchgate.net/figure/The-Historical-Timelines-on-Emergence-of-Botulinum-Toxin-as-a-Therapeutic-Agent_tbl1_311432615 [accessed 29 May, 2020]


    OVERVIEW OF BOTULINUM TOXIN(BT) 

    Botulinum toxin which is to be had within the marketplace is purified exotoxin of the anaerobic bacteria, clostridium botulinum.     

    This neurotoxin is the motive of serious paralytic illness, botulism.     

    Seven types of botulinum toxins had been isolated but simplest two, Types A and B, had been made commercially available.     

    The incubation period after ingestion is 18-36 hrs   

    In human beings, botulism is particularly as a result of Types A, B, E, and seldom F, whereas in animals, it's miles resulting from Types C and D.     

    The toxin is heat labile and denatured with the aid of cooking   

    Initially, most effective botulinum toxin A was available commercially on prescription but greater recently, Type B additionally available within the marketplace.   

    Commercially available botulinum toxin is the purified exotoxin of the anaerobic bacteria,Clostridium botulinum.     

    This equal neurotoxin is the motive of the uncommon but critical paralytic illness,botulism.     

     
    Seven varieties of botulinum toxin have been isolated however best two, types A and B, have been made commercially to be had.

    MECHANISM OF ACTION


    Photo credit: https://www.stonybrook.edu/commcms/ojima_group/research/BoNT.html 


    Photo credit:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4672850/#__ffn_sectitle


    DOSAGE

    • Injection site

    Photo credit: https://www.pinterest.com/pin/175288610482939735/


    • Units

    Photo credit: https://www.westlakedermatology.com/blog/how-much-botox-do-i-need


    BOTOX DENTAL THERAPEUTIC USES

    • Temporomandibular disorders (TMD) cases
    • Bruxism and clenching cases
    • Facial pain cases including treating trigger points
    • Treatment of angular cheilitis
    • Gummy smiles
    • Orthodontic relapse and depressed orthodontic appearance
    • Reducing muscle hyperactivity for retention of removable prosthodontics
    • Sialorrhea
    • Oromandibular dystonia
    • Trigeminal neuralgia.
    • Pathologic clenching

    TREATMENT OF TEMPOROMANDIBULAR DISORDER 

    The term “temporomandibular problems” refers to an often poorly understood collective of clinical issues involving the masticatory musculature, the temporomandibular joints and related systems orsome mixture. 

    Botulinum toxin is a valuable clinical tool in the control of the myofascial thing of temporomandibular disorders. 

    The first line treatment method for temporomandibular disorders includes physiotherapy, exercises,behavioural type therapy, oral appliances (most often stabilizing kind), anti-inflammatory medications, muscle relaxants, analgesics or some mixture of those.   

    Rarely surgical intervention is indicated. 

    Botulinum toxin can be a beneficial adjunct, specifically whilst these have failed to provide good enough remedy, mainly in instances related to muscular hyperactivity.

    TMD SIGN AND SYMPTOMS 

    Photo credit: https://www.dentalclinique.us/tmj-treatment.html


    TREATMENT OF BRUXISM 

    Bruxism is the overall time period that refers to each clenching and grinding of the enamel. 

    It ends in the destruction of wholesome dentition at the side of exacerbation of the periodontal disease, inflicting TMD, complications and facial pain.

    Bilateral injections of toxin are given into the masseter and temporalis muscle groups in bruxism and TMD patients. 

    Injecting the right quantity will lower the energy of contractions of the muscular tissues of mastication similarly to, improve capability for mastication and talking

    History of severe bruxism who were refractory to medical and dental procedures, to them botulinum toxin TypeA injections were given into the masseters (mean dose: 61.7 U/side; range 25 U to 100 U). 

    Left-before treatment, Right-after treatment

    Photo credit: http://www.mintdental.ie/new-blog-avenue/2017/4/28/bruxism-teeth-grinding


    TREATMENT OF FACIAL PAIN

    Neurotoxins may be usually implemented to diverse muscles of the face and mastication,   which includes the trapezius, depressor anguli oris, sternocleidomastoid, splenius capitus,   frontalis, procerus, corrugator, orbicularis oris, orbicularis oculi,masseter,temporalis mentalis, and pterygoid muscle tissues for the TMD and facial pain instances.   

    The masseter and temporalis muscle mass are continually dealt with bilaterally even if simplest one facet of the face is involved.

    Photo credit: https://dentox.com/botox-edu-news/give-patients-significant-relief-severe-facial-pain-botox/


    TREATMENT OF ANGULAR CHEILITIS

    Angular cheilitis is the second most common infection of the lip. 

    It is the inflammation of 1 or more corners of the lip, or the whole lip. 

    Cheilitis is an opportunistic infection on the whole via fungus and bacteria. 

    The factors that predisposes one to having this condition include nutritional deficiencies, conduct which includes lip licking and remaining mouth for long intervals of time. 

    Other elements include immunosuppression due to some illnesses and dehydration resulting in dry lips. 

    This situation can closing for a few days, but in some cases it could persist for an indefinite quantity of time. 

    One of the best methods is the remedy the usage of Botox. 

    This is a muscle relaxant toxin this is in the main used inside the development of facial features, like brief elimination of wrinkles. 

    Botox is accredited for use in clinical approaches by means of the FDA. It is consequently a safe treatment for such conditions.   

    Photo credit: https://healthjade.net/angular-cheilitis/


    Photo credit: https://www.skinmdandbeyond.com/mouth-lip-rejuvenation/ 


    TREATMENT OF GUMMY SMILES

    Gummy smile refers to the immoderate show of gum tissue when smiling, regularly considered unattractive.
    • Causes of gummy scale
      • Overgrowth of the upper jaw
      • Short upper lip
      • Hyperactive upper lip: Most common in females
      • Overgrowth of gum tissues
    An injection of Botox above the upper lip reduces the lifting action of lip muscle tissues, thus lowering the show of gum tissues. Treatments provide sufferers with a greater aesthetic and delightful smile

    Photo credit: https://doi.org/10.1016/j.ijscr.2017.11.055 

    Photo credit: https://www.cmcmohali.com/botox-gummy-smile/


    TREATMENT IN ORTHODONTICS

    Relapse has been a continual hassle for many widespread and orthodontic dental practitioners as teeth may additionally keep to shift properly after orthodontic treatment is complete. 

    Many patients have a hyperactive mentalis muscle that regularly disrupts the alignment of tooth and may additionally reason muscle groups to spasm. 

    However, BTX can reduce muscle contraction intensity, allowing muscle groups to be retained to work well over time. 

    This ought to revolutionize how we address orthodontic relapse as more dental practitioners emerge as acquainted with botulinium uses.    

    Photo credit: https://www.acuityortho.com/botox/


    TREATMENT IN REMOVABLE PROSTHODONTICS 

    Increasing numbers of patients are receiving implant treatment to assist stabilize their dentures, there will always be sufferers who either cannot afford for implant therapy or are not suitable applicants for the remedy. 

    Many of those sufferers have hyperactive muscle tissues, making it tough a to retain dentures in their mouths. 

    Muscle training with the help of BTX may also provide remedy in these instances.

    TREATMENT IN SIALORRHEA

    Excessive saliva production or the incapacity to maintain saliva inside the mouth can end result in sialorrhea, greater commonly known as drooling. 

    Sialorrhea treatments consist of behavioral or occupational therapy and pharmaceutical treatments like scopolamine. 

    Botulinum toxin has been proven to be effective inside the management of sialorrhea. 

    This involves injection into the salivary glands, commonly with electromyographic guidance. 

    However, also BTX can be used to treat sialorrhea through injection into the parotid and submaxillary salivary glands, which inhibits the stimulation of the cholinergic receptor. 

    This use of BTX to treat sialorrhea does no longer deal with any muscle groups, but it does result in saliva reduction. 

    However, this remedy need to be done carefully as too much neurotoxin can end result in mastication difficulties, incapacity to swallow and dry mouth.   

    A 20-year-old female patient with intellectual disability suffering from extensive sialorrhea (drooling) and dental malocclusion: the saliva outcome beyond the lip margin is uncontrolled.

    Photo credit: http://arh.amegroups.com/article/view/3674/4424


    Botox injection into the salivary gland

    Photo credit: https://www.aboutkidshealth.ca/Article?contentid=2444&language=English 


    TREATMENT OF OROMANDIBULAR DYSTONIA

    This kind of muscular spasm consequences from spasm of all muscle tissues of mastication and associated mandibular muscle tissue. 

    This disorder places barriers on finishing the fundamental oral hygiene important to save you oral disease. 

    It leads to unintended opening and closing of the mouth in vertical, lateral, and protrusive directions

    This situation frequently outcomes in involuntarily chewing of the tender tissue within the mouth and can also intrude with ordinary chewing and speaking
    • Masseter injections of BTX have been reported to resolve some of these muscle dysfunctions. other impairments can include: 
      • Restrictions on dental treatment, difficulty with eating and diminished oral utility. 
      • Botulinum toxin treatment to the masticatory musculature diminishes the effects of hyperfunctional or spastic muscles
    • Muscle name and its Functions of BT injection
      • Temporalis   

    Close the jaw Posterior fibers retract the mandibleMove jaw to the same side

    • Masseter

    Close the jaw by elevating the mandible

    • Medial pterygoid

    Close the jawProtrude the jawMoving the jaw to the opposite side

    • Lateral pterygoid   

    Open the mouthProtrude the jawMove the jaw to the opposite side

    • Digastric   

    Open the jawElevate the hyoid bone

    • Mylohyoid   

    Open the jawRaise the floor of the mouth

    • Geniohyoid   

    Open the jawElevate and draw hyoid bone forward 



    Photo credit: https://www.mussenhealth.us/cell-carcinoma/oromandibular-dystonia.html 



    1: zygomaticus major muscle, 2: orbicularis oris muscle, 3: mentalis muscle, 4: masseter muscle, 5: temporalis muscle, 6: coronoid process, 7: posterior belly of the digastric muscle, 8: anterior belly of the digastric muscle, 9: buccinators muscle, 10: sternocleidomastoid muscle, 11: trapezius muscle, 12: platysma, 13: medial pterygoid muscle, 14: lateral pterygoid muscle


    Photo credit: https://sites.google.com/site/oromandibulardystoniaenglish/home/treatment-of-oromandibular-dystonia/botulinum-therapy



    TREATMENT IN TRIGEMINAL NEURALGIA

    It is a unilateral neurological disorder affecting orofacial muscle mass leading to acute severe pain. 

    Botox may be used as an adjunctive remedy modality in these patients which acts on nerve endings, thereby reducing the severity of the pain

    Photo credit: https://dentox.com/botox-edu-news/botox-shown-offer-significant-relief-one-form-severe-facial-pain/ 


    PATOLOGIC CLENCHING

    Pathologic clenching is a sickness leading to chronic trauma to teeth, gingiva, and underlying tissues. 

    Low doses of botulinum toxin Type A can potentially lessen this ailment. 

    Because parafunctional clenching leads to periodontal trauma, proscribing clenching earlier than and after periodontal surgical operation can advantage healing       

    SIDE EFFECTS OF BOTOX THERAPY 

    The muscle tissue injected can be sore for a few days after the injections 

    Botox can purpose temporary partial weakening of the muscles injected 

    When Botox is used for a protracted time, it could purpose atrophy of the muscle groups injected. 

    This atrophy is reversible if the remedy is discontinued 

    There had been reviews of temporary side results which include flu-like signs and symptoms, palpitations, tingling sensations, or nausea. 

    These side results are rare and commonly go away within 1-2 days. 

    A product to consist of a “Boxed Warning” highlighting probably unfavourable reactions associated with distant spread of the toxin effect from the injection site.

    These highlight botulism-like signs and symptoms inclusive of muscle weakness,hoarseness or dysphonia, dysarthria, lack of bladder control, problem breathing, problem swallowing,double or blurred vision and drooping eyelids.     

     

    BOTOX SIDE EFFECTS 

    Photo credit: https://www.aafp.org/afp/2014/0801/p168.html


    CONTRAINDICATIONS OF BOTOX THERAPY 

    Hypersensitivity to any botulinum toxin preparation

    Infection at the proposed injection site.

    CONCLUSION

    Botulinum toxin has truely been confirmed to have big value in the control of some forms of orofacial pain, specifically myogenous temporomandibular problems in instances wherein the affected person is unresponsive to the less invasive therapeutic modalities or, at times, together with them. 

    Most of the situations for which a dentist would possibly use botulinum toxin are not amongst the authorised applications (off-label use). 

    Therefore patients have to be properly knowledgeable prior to consenting. 

    Chemodenervation the use of botulinum toxin is useful in lots of the conditions of dentistry. 
    The controlled use of this remedy is more important rather than its radical use.

    REFERENCE: 







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