Dentistry Botox And Fillers

Authors:Dr. Shourya Sharma,Dr. Natasha Gambhir
Look at all of the technology choices that we now have in dentistry which we have never had before. With technology, the choices are becoming more complicated and evolved over time. The right choice of technology for your office can rapidly improve patient care and your productivity, which translates to your bottom line. The wrong technology can make clinical care more invasive, more complicated, and put your office out of business. This is why it is crucial for you to have a well thought out process as to how you evaluate which technology belongs in your office
My friends, if you are still practicing cosmetic or aesthetic dentistry you are practicing in 1995. In year 2014 we practice facial esthetics which incorporates the best we have in aesthetic dentistry and takes it to its true meaning. We as general dentist and dental specialist, treat all of the oral and maxillofacial structure every time we treat a patient, weather we realize it or not. Its time for dentist to be cognizant of the fact of what we are doing when we accomplish any kind of dental treatment. Every thing you do affects all of the muscles and facial structure in the entire head and neck. When you place those crowns, veneers, dentures, implants or perform any prosthodontic treatment, the entire relationship of the lips, cheek, chin, nasolabial folds and the entire face begins to change. If you have just placed a veneer on your patient, you have delivered great looking teeth, but not necessarily a great looking smile. What is aesthetic about having beautiful veneers on the upper teeth with deficient or uneven lips; a lip that hides the teeth; and /or radial lip lines (smoker’s lines)? In my opinion, it is time for every general dentist to investigate and learn how to integrate Botox and dermal fillers into his or her practice. These minimally invasive procedures are nonsurgical facial injectables treatments that can improve the patient’s dentofacialaesthetics. They are also well-proven therapies for temporomandibular joint disorders (TMD) and facial pain patients. Currently, nearly all states in USA allows dentist to use Botox and dermal fillers for dental and aesthetics and dental therapeutic uses in oral and maxillofacial structure and it also same in most of European countries where dentist have incorporated it in there day to day dental practice . The use of Botox and dermal fillers is one of the hottest topics in dentistry at the present time.
This same concept applies to making choices on new procedures that you want to offer in your practice. Integrative procedures like frontline TMJ/myofacial pain techniques, Botox, and dermal fillers only require learning new skills with no capital investment and no obstacles in your way. Non-integrative procedures such as sleep apnea have obstacles that you can’t control but can be worked through.

So What Is Botox
Commercially available Botulinum toxin is the purified exotoxin of the anaerobic bacteria, Clostridium Botulinum. This same neurotoxin is the cause of the rare but serious paralytic illness, botulism. Seven types of Botulinum toxin have been isolated but only two, types A and B, have been made commercially available. Initially, only Botulinum toxin A was available commercially on prescription but more recently, type B also came on the market. The Food and Drug Administration (US) has only approved Botulinum  toxin type A for treatment of cervical dystonia (severe neck muscle spasm), severe primary axillary hyperhidrosis (excessive axillary sweating), blepharospasm (spasm of the eyelids) and temporary improvement in the appearance of moderate to severe glabellar lines (wrinkles).^1,2,3 Type B Botulinum toxin has approval for cervical dystonia.

How It Works
The toxin acts by preventing the release of acetylcholine from presynaptic vesicles at the neuromuscular junction resulting in an inhibition of muscular contraction. This blockade is temporary, varying from three to four months, after which sprouting of new axon terminals result in a return of neuromuscular function. Therefore, treatment with Botulinum toxin cannot be considered curative but a palliative and symptomatic approach to the management of a problem. The toxin has also been shown to block acetylcholine release at parasympathetic nerve terminals.  More recently, Botulinum toxin has been suggested as part of the armamentarium for the management/treatment of various orofacial conditions and a considerable body of literature has been developed describing or investigating its efficacy and safety.

Safety and Adverse Effects
In general, adverse reactions are uncommon and relatively mild and transient. They are more common at or near the site of injection. These include dry mouth, dysphagia, dysphonia, transient muscle paralysis, headache, urticaria and nausea.² Often, but not always, these side effects are noted when the dose exceeds that recommended. In 2008/2009, both Health Canada and the FDA revised the prescribing information for the commercially available botulinum toxin A products to include a Boxed Warning highlighting potentially adverse reactions related to distant spread of the toxin effect from the injection site.^{1, 5,6 2,3,} These highlight botulism-like symptoms such as muscle weakness, hoarseness or dysphonia, dysarthria, loss of bladder control, difficulty breathing, difficulty swallowing, double or blurred vision and drooping eyelids. These effects can occur anywhere from a day to several weeks after treatment at unrelated sites.^{1, 2, 3,} and ^5,6,7,8 although rare,
Deaths have been reported. Children treated for spasticity seem particularly susceptible but adults have also been affected. Serious adverse reactions have occurred at therapeutic or lower doses.

Temporomandibular Disorders
The term “temporomandibular disorders” refers to an often poorly understood collective of clinical problems involving the masticatory musculature, the tempormandibular joints and associated structures or some combination. The disorders are often intermingled with other chronic pain disorders including fibromyalgia, chronic fatigue syndrome or tension type headache. Treatment is dependent on a thorough history and examination of the patient with a view to developing a clinical diagnosis and attempting to establish the basis for the patient’s complaints. These symptoms can originate from the tissues of the joints themselves or the related musculature. There is evidence that Botulinum toxin is a valuable clinical tool in the management of the myofascial component of temporomandibular disorders. The first line treatment approach for temporomandibular disorders includes physiotherapy, exercises, behavioural type therapy, oral appliances (most often stabilizing type), anti-inflammatory medications, muscle relaxants, analgesics or some combination of these. Rarely surgical intervention is indicated. Botulinum toxin can be a useful adjunct, particularly when these have failed to provide adequate relief, particularly in cases involving muscular hyperactivity. There is evidence that it has a place in the treatment of dystonia, masticatory muscle hyperfunction, myofascial pain and, to some extent, bruxism.^9,10-15 Similarly, it may have a place as an adjunct to appropriate physical therapy in some cases of whiplash injury.¹⁶ Although there is a paucity of supportive research, there is a suggestion that botulinum toxin may also have a supportive role in temporomandibular joint surgery.^17,18 These applications are off-label uses and patients should be so informed.

Other Orofacial Pain Disorders
There is still inadequate, well controlled research on the effectiveness of Botulinum toxin in most other orofacial and related conditions. In some cases, the results are in conflict. Although research is still ongoing, there may be a place for it in the management of some forms of headache, migraine and tension type in particular where the more common therapeutic modalities have been unsuccessful.^19,20,21 Its value in orofacial neuropathic conditions is yet unproven. Again, patients should be informed of these off-label applications before making an informed decision.

Other Applications
Botulinum toxin has been shown to be effective in the management of sialorrhea.^{22, 23} this involves injection into the salivary glands, usually with electromyographic guidance. It has been suggested as a means of reducing the load on newly placed implants but there is no strong scientific evidence that there is any significant effect of the success or survival of the implant. It has been well demonstrated that Botulinum toxin will reduce facial wrinkles. Some have suggested its use to treat high lip lines or perioral age related changes. The scientific evidence in support of much of this is weak and the application is once again an off-label use.²⁴

References
1. Early Communication about an Ongoing Safety Review of Botox and Botox Cosmetic (Botulinum toxin Type A) and Myobloc (Botulinum toxin Type B). 2009-01-27.
2. Follow-up to the February 8, 2008, Early Communication about an Ongoing Safety Review of Botox and Botox Cosmetic (Botulinum toxin Type A) and Myobloc (Botulinum toxin Type B). Food and Drug Administration (United States), 2009-04-30.
http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInfor mationforPatientsandProviders/DrugSafetyInformationforHeathcar eProfessionals/ucm143819.htm
3. Information for Healthcare Professionals: OnabotulinumtoxinA (marketed as Botox/Botox Cosmetic), AbobotulinumtoxinA (marketed as Dysport) and RimabotulinumtoxinB (marketed asn Myobloc). Food and Drug Administration (United States), 2009-08-03.
www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformation forPatientsandProviders/ucm175011.htm 4. Unclassified Therapeutic Agents. Health Canada. http://www.hcsc. gc.ca/fniah-spnia/nihb-ssna/provide-fournir/pharmaprod/ med-list/92-00-eng.php
5. Health Canada reviewing issue of distant toxin spread potentially associated with Botox and Botox Cosmetic. Health Canada. http://www.hc-sc.gc.ca/ahc-asc/media/advisoriesavis/_ 2008/2008_32-eng/php
6. New Safety Information Regarding Botox and Botox Cosmetic Products. Health Canada. http://www.hc-sc.gc.ca/ahcasc/ media/advisories-avis/_2009/2009_02-eng/php
7. Bakheit AM. The possible adverse effects of intramuscular botulinum toxin injections and their management. Curr Drug Saf 2006;1(3):271-279.
8. Schames J, Prero YD, Schames D, Schames M, Gabriel W, Reed R. Uncontrollable distant effects of botulinum neurotoxin injections. Calif. Dent J. 2009;37:44-45.
9. Ihde SKA, Konstantinovic VS. The therapeutic use of botulinum toxin in cervical and maxillofacial conditions: an evidence-based review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:e1-e11.
10. Sycha T, Kranz G, Auff E, Schnider P. Botulinum toxin in the treatment of rare head and neck pain syndromes: a systematic review of the literature. J Neurol 2004;Suppl 1:119-130.