Review Article

Application of Botulinum toxin Type A:

An arsenal in dentistry

Lakshmana B Rao, Rajashekar Sangur, S Pradeep

Department of Prosthodontics,
Rama Dental College, Kanpur,
ABSTRACT
India
Received : 09-10-09
Review completed : 26-02-10
Accepted : 09-09-10
An extremely effective way of preventing damage to and enhancing treatment of dental hard
tissues and restorations would be to ‘‘de-programme’’ the muscles responsible for excessive
destructive forces and other gnathological-related diseases. The new paradigm is the
intramuscular injection of Botulinum toxin type A (BOTOX) into the affected muscles. It is a
natural protein produced by anaerobic bacterium, Clostridium botulinum. The toxin inhibits
the release of acetylcholine (ACH), a neurotransmitter responsible for the activation of muscle
contraction and glandular secretion, and its administration results in reduction of tone in the
injected muscle. There are seven distinct serotypes of Botulinum toxin, viz., A, B, C, D, E, F,
and G, which differ in their potency, duration of action, and cellular target sites. This paper
describes the different applications of BOTOX in dentistry.
Key words: Botulinum toxin type A, masticatory muscle hypertonicity, pharmaceutical splint,
temporomandibular disorder

There is a clear need to expand the current options available
for the preventive treatment of muscle-generated dental
diseases. A number of diseases affect the masticatory
function including the pathology of the temporomandibular
joint and masticatory muscle dysfunction.[1] The damage
caused by excessive biting forces and dental trauma is usually
treated with intraoral appliances, occlusal adjustments,
sophisticated dental restorations, and/or surgery which are
excellent treatment options, but they are not suitable for
all patients.[2] Orthognathic surgery and neuromuscular
rehabilitation of the occlusion are invasive, irreversible, and
expensive, while orthodontic treatments are irreversible
and expensive for a majority of the patients. Sophisticated
restorations are not only very technique-sensitive, but also
involve the removal of additional healthy tooth material.
The most aesthetic conservative restorations may not
withstand the para-functional forces continually applied
Address for correspondence:
Dr. Lakshmana B. Rao
E-mail: blrao2006@yahoo.co.in
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by some subjects. Intraoral splints can be very effective in
preventing excessive wear and enable the jaw to function
in the most relaxed position. However, some patients do
not like to have appliances in their mouth, because the
appliances impede their normal functions like eating and
speaking. The continued use of analgesics, narcotics, steroids
and anti-inflammatory drugs for associated dento-facial
symptoms are neither ideal nor conducive to health. Though
there is no common treatment for the problems mentioned
above, the most promising and exciting new addition to the
dentist's arsenal is use of Botulinum toxin type A (BOTOX)
for the treatment of such painful conditions.[1,2]
APPLICATIONS OF BOTOX IN DENTISTRY
BOTOX can be used in the following dental disorders:
• Temporomandibular disorder (TMD).
• Dental implants and surgery.
• Prominent gums.
• Masseteric hypertrophy.
• Mandibular spasm.
• Headache, migraine, and trigeminal neuralgia.
• Myofacial pain and neck pain.

PMID:
*** TEMPOROMANDIBULAR DISORDER
DOI: TMD is an umbrella term used to describe a number of
10.4103/0970-9290.87068
diseases affecting masticatory function, which may include
Indian Journal of Dental Research, 22(3), 2011 440
Application of Botulinum toxin in dentistry Rao, et al.
true pathology of the temporomandibular joint as well
as masticatory muscle dysfunction. TMD manifests with
facial pain, joint sounds, headache, periauricular pain,
neck pain, and/or decreased joint excursions.[1,3] Periodontal
and occlusal diseases having an etiology in dysfunction of
masticatory musculature are the key components of TMD.
Muscular spasticity secondary to bruxism, external stresses,
oromandibular dystonia, and psychomotor behaviors are
common etiologic factors of TMD.[1,2] Excessive pathologic
nocturnal clenching (excessive centric grinding of teeth)
of the jaw which in severe cases may manifest as dystonic
bruxism, contributes to TMJ dysfunction in additions to
damage to teeth, bone, joints, and gums. In untreated cases of
excessive pathologic clenching or TMD, tooth decay is more
prevalent because excessive forces can cause microfractures
and abfracturing of enamel, especially around the existing
restorations and may also be followed by gingival recession.[1]
Bruxism (excessive eccentric grinding of teeth) can affect the
muscles solely and/or lead to the formation of TMD causing
joint damage. Chronic patients have headaches, bruxism-
induced TMJ derangement or arthritis and difficulty in
speaking, swallowing, or chewing. The symptoms are
exacerbated by external factors such as fatigue, stress,
and emotional extremes.[4] If sleep bruxism is present, the
most effective way to protect the teeth is with an occlusal
appliance. The problem with occlusal covering appliances is
that they do little or nothing to stop the bruxism and offer
only a brief respite from headaches and bruxism induced
TMJ derangement or arthritis. In general, because of the
numerous presentations of bruxism, the current treatments
available are neither uniform nor universally successful.[1,2,4]
Extra capsular TMD is often transient and usually the
least invasive treatment options are considered best
to commence the treatment. Many of the techniques
currently in use are not ideal for all patients and muscular
relaxation may pose a viable alternative. When muscle
relaxants are used, the clenching reflex can be reduced or
eliminated. A slight relaxation of muscle function reduces
bruxing and is usually insufficient to affect chewing and
swallowing.[5] Prophylactic treatments for incipient TMD
should be instituted for the reduction of both conscious
and unconscious para-functional factors. Treatment of the
myogenic component of TMD has been largely limited
to supportive care. In more severe cases, physiotherapies,
oral pharmacotherapy, biofeedback, and other treatment
modalities usually provide short term and inadequate relief.
Chronic systemic pharmacotherapy is largely unsatisfactory
because of the modest improvements and frequent side
effects.[1,5] Use of muscle relaxants like diazepam can curtail
the activities of many patients. For patients who have failed
with conventional treatment approaches, the least invasive
method is the application of BOTOX injections into the
painful masticatory muscles which can provide relief of
intractable symptoms.[5,6] Freund and Schwartz mentioned
441
BOTOX as a muscle relaxant.[6] Binder and colleagues while
treating patients for facial lines with BOTOX injections,
noted marked improvement of migraine symptoms in those
who had failed to respond to conventional treatment.[3,7]
TREATMENT PROTOCOL FOR TMD
The treatment begins with a lower dose, because it is always
possible to titrate up to a higher dose, if necessary.
• The temporalis component of pain is treated with
bilateral injections of 7.5 U into the anterior vertical
fibers of each temporalis muscle. In more severe cases,
2.5 U are given into the middle and posterior third of
the temporalis muscles. Pain relief for the tendon of
temporalis is achieved with multiple injections of 2.5
U equidistantly spaced in the temple area outside the
orbital rim.
• The masseter component of pain is treated with 5
U injected into the belly of the masseter below an
imaginary line joining the tragus of the ear and the
corner of the mouth.[8]
There are several case reports, which are supporting the
efficacy of BOTOX treatment for TMD:
• Freund et al. conducted a large open-label trial with
46 patients suffering from TMD and found that 150 U
injections of BOTOX to the temporalis and masseter
muscles significantly decreased pain and tenderness and
improved function and mouth opening.[6]
• Tan and Jankovic conducted a long-term open-label
trial on 18 patients with a history of severe bruxism.
Injections of BOTOX given to the masseter muscle
(mean dose: 61.7 U/side; range 25−100 U), yielded a total
duration of therapeutic response of 19 weeks.[9]
• Lee et al. conducted a small open-label trial study to
evaluate the effect of BOTOX on pain in six patients with
limited mouth opening due to TMD. All patients showed
clinical remission of pain symptoms without any adverse
effects during the 5-12 months follow-up period.[10]
DENTAL IMPLANTS AND SURGERY
Implant patients will benefit from pre-surgical BOTOX
treatment. After multiple implants or when immediate
loaded implants are placed, osseo-integration can be
impeded by excessive functional forces in patients with
para-functional habits. Over loading of the implants results
in implant failure by loosening of the implant components
or prevention of osseo-integration. The muscular relaxation
achieved with prophylactic use of BOTOX injections to the
masticatory muscles can be beneficial by allowing implant
structures better osseo-integrated. Maxillofacial fracture
repair often requires multiple fixation sites and hardware
to overcome the strong forces of masticatory musculature.
Overloading of these muscles can prevent fracture callus
Indian Journal of Dental Research, 22(3), 2011
Application of Botulinum toxin in dentistry Rao, et al.
formation. The muscular relaxation achieved with
prophylactic use of BOTOX injections to the masticatory
muscles can be beneficial by allowing fracture healing in a
more stable environment.[11-13]
Excessive forces created by para-functional clenching
impede healing and reattachment of gums and bone
in the mouth following trauma. Low doses of BOTOX
can potentially limit the para-functional clenching and
its intensity and thus allow traumatized tissues to heal.
High doses can be used as a ‘‘pharmaceutical splint,’’
limiting muscle contraction before resetting and during
rehabilitation after fracture of the facial bone, e.g., fractured
mandibular condyle.[1] Because para-functional clenching
contributes to periodontal trauma, limiting clenching before
and after periodontal surgery can benefit in healing. The
use of a splint is often contraindicated because the teeth
should be functional during healing. With significant bone
loss, excessive forces may jeopardize dental stability and
contribute to additional tooth loosening. The same applies
in a patient with bone loss associated with either advanced
periodontal disease or osteoporosis and a strong bite. Bite
force is not diminished with reduced alveolar bone support.
The use of BOTOX may offer an alternative to conventional
splint therapy.[1,2]
Kayikvioglu and colleagues conducted a small open-label
study to prospectively examine the use of BOTOX in five
patients as an adjunct to zygomatic fracture fixation surgery,
in an attempt to reduce the number of fixation sites and to
prevent dislocation of the zygomatic bone. Preoperatively
100 U of BOTOX was injected into the masseter muscle
of the fractured side. After 12−48 h of injection, patients
were operated and muscle denervation was confirmed
by EMG. The temporary paralysis of the masseter muscle
allowed for fewer miniplates and/or microplates inserted
among the patients and resulted in no complications. The
Kayikvioglu group also found similar benefits of adjunct
BOTOX treatment for surgical reduction of mandibular
condylar bone fractures.[13]
PROMINENT GUMS
The display of excessive gingival tissue in the maxilla upon
smiling or the ‘‘gummy smile’’ is both an oral hygiene and
aesthetic issue with no simple remedy. Several surgical
techniques have been reported in the literature for the
correction of hyper-functional upper lip elevator muscles,
such as (a) Rubinstein and Kostianovsky, (b) Miskinyar
(c) Rees and LaTrenta techniques. However, they are not
routinely used to treat gummy smiles. In general, the most
common surgical corrections currently used are the LeFort
I maxillary osteotomies with impaction for skeletal vertical
maxillary excess and gingivectomies for delayed passive
dental eruption with excessive gingival display.
Indian Journal of Dental Research, 22(3), 2011
Excessive gum exposure is frequently attributable to over
contraction of the upper lip muscles, particularly the levator
labii superioris alaeque nasi. When this is the case, a less
invasive approach is to limit muscular over-contraction. If
applied in small, carefully titrated doses, these muscles can
be proportionately weakened with BOTOX, which will
reduce exposure of the upper gums when smiling. Polo
conducted a study in which five patients with excessive
gingival display due to hyper-functional upper lip elevator
muscles were treated with BOTOX under electromyographic
guidance. Patients received one 0.25 U injection per muscle
bilaterally into the levator labii superioris, superioris labii
alaeque nasi, and at the overlap areas of the levator labii
superioris and zygomaticus minor muscles. All the patients
were pleased with the results and the effective increase in
upper lip length upon smiling averaged 124.2% and the
duration of effect ranged from 3 to 6 months and no adverse
effects were reported or observed.[14]
MASSETERIC HYPERTROPHY
Patients who are chronic jaw clenchers frequently present
with masseteric hypertrophy.[15] The increased size of
these muscles is evident in the patient’s facial appearance,
which is often altered, e.g., the jaw can appear swollen and
misshapen. To treat this, surgical resection was commonly
resorted to which often resulted in substantial contracture.
In several small but well-documented clinical trials by
(1) Al-Ahmad, Al-Qudah,[16] (2) Mandel and Tharakan,[17]
and (3) Rijsdijk and Vanes,[18] injection of small aliquots of
BOTOX into the masseter muscles resulted in a sustained
reduction of masseter hyperactivity.
MANDIBULAR SPASM
It is a condition when the mandibular closing musculature
remains semi- contracted or in spasm, resulting in restricted
mouth opening. This type of muscular spasm limits
completing the basic oral hygiene necessary to prevent oral
disease and places restrictions on dental treatment. BOTOX
treatment to the masticatory musculature diminishes the
effects of hyper-functional or spastic muscles, that can
significantly improve function and mouth opening, and
effectively decrease pain and tenderness to palpation.[1-3]
Several case reports have been published, describing the
effectiveness of BOTOX in patients with hemi- masticatory
spasm, which include studies conducted by (1) Cersosimo
et al.,[19] (2) Auger et al.,[20] (3) Kim et al.,[21] and (4) Kim
et al.,[22] where all the patients responded positively to
BOTOX injections.
HEADACHE, MIGRAINE, AND TRIGEMINAL
NEURALGIA
Standard medications used in the treatment of headache and
442
Application of Botulinum toxin in dentistry Rao, et al.
migraine causes a number of side effects, such as stomach
upset, drowsiness, and weight gain. Such side effects for
BOTOX treatment are relatively rare. BOTOX 25−75
U injected into pericranial muscles relieves headache by
relaxing the over active muscles by blocking nerve impulses
that trigger contractions. For migraines, there is no muscle
component involved. It is believed that BOTOX works by
blocking the protein that carries the message of pain to the
brain and relief typically takes effect in 2−3 weeks after
injection. The longer the treatment duration, the better
the pain relief.[2,23] According to Elcio, excruciating pain
associated with inflammation of the trigeminal nerve of
the head and face can be substantially relieved by injections
of BOTOX.[24] According to Lawrence Robbins, BOTOX
actually is an anti-inflammatory substance, decreasing, or
antagonizing the inflammatory (neuronal/brain) effects of
W (Calcitonin gene-related peptide).[25]
MYOFACIAL PAIN AND NECK PAIN
The etiology of myofacial pain syndrome is incompletely
understood. Some clinicians believe that it characteristically
results from either an acute episode of muscle overload or
from chronic and/or repetitive muscle overload. Active
myofacial trigger points, which cause pain, exhibit marked
localized tenderness and often refer pain to distant sites and
disturb motor function. Injection of muscles with BOTOX
has been reported to be effective for myofacial pain caused
by trigger points.[26]
Jennifer Warner, reported pain relief in 25 patients with
chronic neck pain, after a single injection of Botox delivered
to the affected neck muscle combined with standard
physiotherapy.[27]
OTHER USES OF BOTOX
• The conventional treatment of ranula is surgical
procedure. However, an innovative therapy with
BOTOX is minimally invasive and the ranula gets
resolved with minimal complications.[28]
• Recurrent dislocation of the mandibular condyle poses
a difficult problem for affected patients. In the course of
time, dislocations often become more frequent and more
difficult to avoid. Even with good patient compliance,
conservative treatment is often not sufficient. Operative
procedures have also been described for the treatment of
temporomandibular joint dislocation. On the other hand,
BOTOX injections into the lateral pterygoid muscles
offer the option of a predictable and prolonged period
without renewed dislocation.[29]
• Facial aesthetics: The use of BOTOX in facial aesthetics
for the treatment of wrinkles has recently become more
popular as an alternative to surgical techniques.[30]
• Habitual clenchers are more prone to snoring and sleep
443
apnea. When BOTOX is injected into the masticatory
muscles that hold the jaw in a retruded position, it
enables the patient’s jaw to move slightly forward during
sleep. This opens the air way sufficiently to reduce
snoring.[2]
• Diagnostic application of BOTOX can be used to verify
whether the correct diagnosis has been established or not.
The pain originating from the pulp will not be relieved
when BOTOX is injected into the muscles. Hence, the
patients will be certain about the muscular or pulpal
origin of the toothache. The diagnostic applications are
limited only for the elimination of pain originating from
muscles and the pain originating from other structures
are not relieved and can be clearly differentiated.[3]
LIMITATION OF BOTOX
The therapeutic approach using BOTOX inhibits masticatory
function temporarily and the masticatory forces will
eventually return to previous levels once the effect of the
drug has subsided.
CONTRAINDICATIONS AND ADVERSE EVENTS
The relative contraindications include pregnancy,
lactation, neuromuscular diseases (myasthenia gravis,
Eton-Lambert syndrome), motor-neuron diseases,
concurrent usage of amino glycosides and sensitivity to
toxin. The potential adverse effects of Botulinum toxin in
oromandibular disorders include facial nerve palsy, pain at
the injection site, flu-like symptoms, non-targeted muscle
weakness, dysphagia, and hematoma. These complications
are generally transient and resolve within a couple of
weeks.[1,7]
PATIENT SELECTION
BOTOX therapy is appropriate for patients in whom other
preventive treatments and medications are poorly tolerated
or contraindicated, patients who are refractory to other
treatments, special patient populations, and patients who
simply prefer this treatment.[2]
DISCUSSION
BOTOX produces partial chemical denervation of the
muscle resulting in localized reduction in muscle activity.
BOTOX can be used as a sole therapy or as an adjunct to oral
medication. Adding 4 ml of 0.9% preservative-free normal
saline solution makes injections and the preparation should
be used within 4 h. The potency of BOTOX is expressed as
mouse units. A unit of BOTOX is defined as the LD50 for a
colony of 20 gm Swiss-Webster mice,[31] extrapolated to the
70 kg human and each 0.1 ml contain 2.5 U of BOTOX. It
is dispensed in small vials containing 100 U or 500 U. The
Indian Journal of Dental Research, 22(3), 2011
Application of Botulinum toxin in dentistry Rao, et al.
lethal dose of BOTOX in humans is not known. Although
it has been estimated to be about 3000 U.[2,8] The usual
maximum dose recommended for dental applications at an
injection session is about 80−100 U. It means that 30 vials of
BOTOX will have to be injected before a potentially lethal
outcome. There is such a huge disproportion between the
clinical dose and the lethal dose that a fatal overdose is
almost impossible. Before injecting Botox into the muscle
and/or joint and/or skin, the skin has to be cleaned with
an alcohol/betadine/chlorhexidine swab. For muscle
injections, the site to be injected should be determined by
using a small electric recorder or a larger machine called an
EMG machine, which helps in correctly locating the area
of the muscle to be injected. Ultrasound-guided injections
may also be used for deeper joints or muscles.[31] BOTOX is
injected using 1 ml tuberculin syringe and 0.30 gauge half
inch needle.[8] Injections of a small amount of this toxin
into a muscle produces atrophy and weakness within 1−20
days and recovers over 2−4 months as new terminal axons
sprout and restore transmission.[32] Injections are spaced out
for a minimum of 3 months to minimize the risk of antibody
formation to the protein,which would prevent BOTOX from
working the subsequent time. Specialized equipment can be
used for more accurate injections that include:
• EMG-guided injections (with the NeuroMax 1004).
• Peripheral nerve stimulator (NS 272).
• Ultrasound-guided injections (including the Canadian
Centre for MSK ultrasound).
• MD injectors (Botox Therapeutic).[31]
Botulinum toxin type A is marketed worldwide under
the name BOTOX (Allergan, Inc. Irvine, CA, USA) and
in Europe as Dysport (SpeyWood Pharmaceuticals Ltd.,
Maiden head, UK).[2,8] Another Botulinum toxin type A from
Germany called Xeomin is also available. It is equipotent
to BOTOX but does not have to be refrigerated and has
no complexing proteins (theoretically reduced risk for
developing antibodies) that would prevent it from working
effectively.[31] The FDA approved Botulinum toxin type B
for the treatment of cervical dystonia is marketed under
the trade name ‘‘Myobloc’’ (Elan pharmaceuticals) in USA[2]
and ‘‘NeuroBloc’’ (Solstice Neurosciences, Inc.) in Europe.[8]
CONCLUSION
It is evident that the use of Botulinum toxin in the dental
profession has a great potential. BOTOX paralyzes or
weakens the injected muscle but leaves the other muscles
unaffected. The injections block the extra muscular
contractions but leave enough strength for normal use.
Intra muscular injections of BOTOX re-establishes the
balance between masticatory closing and opening muscles,
Its use relieves muscle pain, reverses masseteric hypotrophy
with improvement of facial outlines, and restores normal
kinetics of TMJ.
Indian Journal of Dental Research, 22(3), 2011
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How to cite this article: Rao LB, Sangur R, Pradeep S. Application of Botulinum
toxin Type A: An arsenal in dentistry. Indian J Dent Res 2011;22:440-5.
Source of Support: Nil, Conflict of Interest: None declared.
Indian Journal of Dental Research, 22(3), 2011
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