Botox

Question 1

When can general dentists use Botox?

Answer 1

• Botox & dermal fillers
  
  • tx functional or aesthetic dental conditions

Question 2

Botulinum Toxin (BTX)

Answer 2

• Most potent neurotoxin
  
  • natural
• Produced by Gram (+) anaerobic bacteria→Clostridium Botulinum
• 3 antigen subtypes
  
  • A, B, C1, D, E, F, G, H
• Incubation Period:
  
  • 18-36 hr after ingestion
• Heat Labile
  
  • denatured by cooking

Question 3

How does Botulism occur?

Answer 3

• Ingest contaminated food
• Toxin → peripheral cholinergic nerves
  
  • Blocks acetylcholine release
• Results:
  
  • Bilateral symmetric descending neuroparalytic illness

Question 4

What types of Botulism occurs in humans vs animals?

Answer 4

• Humans:
  
  • Types: A, B, E, F(rare)
• Animals:
  
  • C & D

Question 5

Type A Botulinum Toxin

Answer 5

• most common for cosmetics
• 3 forms:
  
  • Botox
  • Dysport
  • Xeomin

Question 6

Type B Botulinum Toxin

Answer 6

• 1 form
  
  • MyBloc

Question 7

What does each vial of BOTOX contain?

Answer 7

• Clostridium botulinum Type A
  
  • 100 units (U)
• Albumin Human
  
  • 0.5 milligrams
• Sodium chloride
  
  • 0.9 mg

Question 8

Botox MOA: (w/Botox & no Botox)

Answer 8

• BTXA inhibits release of acetylcholine (Ach)
  
  • at neuromuscular junction
• Large Dose=complete paralysis
  
  • Therapeutic Dose: Partial activity
• NO BOTOX:
  
  • Ach released→ Muscle Contraction

Question 9

Botox Therapy: Systemic Side Effects

Answer 9

• Anxiety
  
  • Dizziness, Drowsiness, headache, Dry mouth, Dry Eyes
• Pharyngitis
  
  • dysphagia (difficulty swallowing)
  • facial pain
  • flu-like symptoms
• Can’t focus eyes
  
  • drooping eyelid/eyebrow
  • double/blurred vision
  • Sensitive to light
• Indigestion
  
  • Nausea
  • Swearting
  • Fever
  • Chills
  • Allergic rxn
    
    • Rash
    • itching
• Dyspnoe
  
  • chest tightness
  • face edema
  • hoarse voice
  • Respiratory infection
  • anaphylaxis
  • urticaria
  • erythema multiforme
  • No bladder control
  • No Strength
  • paralysis
  • seizures

Question 10

Botox Therapy: Local Side Effects

Answer 10

• Muscle soreness
• Partial muscle weakness (temporary)
• Muscle Atrophy
  
  • prolonged use of botox
  • reversible if discontinued
• Redness
• tingling
• bruising
• swelling
• bleeding

Question 11

Botox: Contraindications

Answer 11

• Aminoglycoside antibiotics
• aspirin
• chloroquine
• calcium channel blockers
• quinine
• Pregnant or Nursing women
• Children
• Cardiovascular Disorders
• Neuromuscular disorders
  
  • Myasthenia Gravis
• Impaired Hemostasis
• Pre-existing infection at injection site
• Skin Infections
  
  • Eczema
  • psoriasis
• 65+ -Emotional
• Botulinum hypersensitivity

Question 12

What are the uses of Botulinum toxin type A in Dentistry

Answer 12

• Bruxism
• Facial Nerve palsy/paresis
• Gummy Smile
• Headache
• Migraine
• Massetric Hypertorphy
• Mandibular Spasm
• Muscle retraining during Ortho
• Myofascial Pain
• Oromandibular Dystonia (OMD)
• oral surgery-Implants
• Salivary Gland Disorders
• Trigeminal Neuralgia
• Postherpetic Neuralgia

Question 13

Myofascial Pain

Answer 13

• Muscle Pain & tenderness
  
  • Mastication Muscles
  • Trigger point/Band Muscles
• Botox
  
  • reduces hyperactivity
  • temporary alleviate pain & dysfunction
    
    • Results: Inconclusive (due to etiology)
      
      • Myositis=cause of pain
        
        • can’t treat w/Botox
        • lacks anti-inflammatory
      • not always muscle hyperactivity

Question 14

Bruxism

Answer 14

• Severe Bruxism
  
  • inject masseter muscles
  • Therapeutic response: 19 weeks

Question 15

Oromandibular Dystonia (OMD)

Answer 15

• movement disorder
  
  • involuntary spasms & muscle contractions
• difficulty speaking, swallowing, and eating
• Forms: Muscle injected
  
  • Jaw-Closure dystonia
    
    • Bilateral Masseter muscles
  • Jaw-Opening Dystonia
    
    • Lateral pterygoids
  • Lingual Dystonia
    
    • Tongue muscles
• Recommended dose: 30 U per side

Question 16

Massetric Hypertrophy

Answer 16

• Enlarged masseter muscles
  
  • Asymptomatic
    
    • unilateral or bilateral
• Inject Masseter Muscle
  
  • 100 U of BTXA

Question 17

Mandibular Spasm

Answer 17

• Semicontracted or muscle spasms that close jaw
• Trismus→ Difficulty Eating
  
  • Masseter M.
    
    • 25 U
  • Temporalis M
    
    • 10 U

Question 18

Gummy Smile

Answer 18

• Excess gums
  
  • due to hyper-fxnal upper lip muscles
    
    • Nasalis
    • orbicularis oculi
    • levator labii superioris
    • Levator labii superiors alaeque nasi
    • levator anguli oris
    • Zygomaticus major
• Recommended Dose of BTX:
  
  • Levator labii superiori & Zygomaticus→ 2.5 U
  • Orbicularis Oculi → 1.25 U

Question 19

Dental Implants and Jaw/Oral Surgery

Answer 19

• Implant failure due to:
  
  • No osseointegration
  • Parafunctional habits
• Maxillofacial fractures (Zygomatic & Condylar)
  
  • require hardware to overcome masticatory muscle forces: prevent callus formation
  • Prophylactic injection: 100 U BTXA
    
    • bilateral masseter muscle
    • 12-48 before surgery
    • Reduce forces
• Periodontal Surgery
  
  • BTX reduce perio trauma due to excessive muscular function

Question 20

Headache and Migraine

Answer 20

• BTX
  
  • Decrease muscle contraction by
    
    • prevent ACh release from presynaptic terminal
  • Inhibits neurotransmitter transmission at gamma motorneurons in muscle spindle
    
    • decreases muscle activity
  • Enter CNS and modulate pain by:
    
    • inhibit release of substance P from trigeminal nerve endings
  • Reduce parasympathetic outflow
    
    • leads to analgesia
    • Chronic Headaches
• Doses of BTX:
  
  • Headache and migraine:
    
    • Range: 10-150 U
    • Cluster Headache:
      
      • 24- 150 U of BTXA or
      • 1200 U BTXB

Question 21

Trigeminal & Postherpetic Neuralgia

Answer 21

• Trigimenal Neuralgia
  
  • BTX:
    
    • inhibits:
      
      • exocytosis of ACh and other neurotransmitters
      • release of NE and ATP from postganglionic sympathetic nerve endings:
        
        • Analgesic effect
        • Reduces central and peripheral sensitization
  • Dose: 20-50 U
    
    • trigger zone or masseter m.
• Postherpetic neuralgia
  
  • alternate tx modality
  • Dose: 15 U intradermally
    
    • inhibits release of:
      
      • formalin-induced glutamate
      • substance P
      • CGRP
    • direct effect: Sensory neurons
      
      • Indirect effect: CNS
    • Pain decreases to mild & tolerable levels in 1st week

Question 22

Facial Nerve Palsy/paresis

Answer 22

• Paresis=Incomplete Loss of Facial N fxn
  
  • Paralysis=complte loss
• Unilateral Palsy
  
  • affects balance b/w R & L side of face
  • Causes Asymmetry
• BTXA Dose: 10-80 U
  
  • intra-muscular
  • contralateral lower facial muscle
    
    • weakens & restores facial symmetry
  • Side effect: Drooling

Question 23

Salivary Gland Disorders

Answer 23

• BTX
  
  • block cholinergic parasympathetic secretomotor fibers of salivary gland
  • Tested in:
    
    • sialorrhea
    • Frey’s Syndrome

Question 24

Retraining Muscles during Ortho Treatment

Answer 24

• prevent relapse of ortho in patients w/stronger muscle activity
  
  • mentalis m.
• Reduced intensity of muscle post treatment & overtime
• retrained to more physiologic movement