Botox - an interesting post!

From: Joel M. Eichen, D.D.S. (joeleichen_at_yahoo.com)
Date: 06/07/04 

Date: Mon, 07 Jun 2004 06:11:02 -0400

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From: webmaster@dentaltown.com Add to Address Book
To: joeleichen@yahoo.com
Subject: RE: Has anyone taken this course - Botox for Dentistry
Date: Sun, 6 Jun 2004 17:55:02 -0700
      
 
On June 6, 2004 at 5:54:59 PM 'howard' posted....

Howard,

I am unable to send this article to your site (your site will not
accept it). Please can you post it with my permission?

Regards

Howard Katz DDS

 
 

CAN BOTULINUM TOXIN A (BOTOX) SAVE YOUR TEETH AND ENHANCE YOUR SMILE?

 

By Howard Katz DDS

 

Modern dentistry has trained the general public to demand and accept
innovative treatments from their neighborhood dentist. There was a
time when you had a toothache you would go to a dentist to pull your
tooth out - that is all they were trained to do. Dentists have not
always performed the specialized, sophisticated treatments that they
do today like restore and replace teeth with implants, root canal
treatments, crowns and cosmetic dentistry, straightening teeth with
invisible braces. As successful treatments became more predictable
and acceptable more and more general dentists performed them.

 

    

Dental disease is caused by two predominate causes. Treatments have
been designed to combat the effects of these:

                                 A) micro-organisms that destroy
dental hard tissue and provoke the immune system to destroy gums and
bone

                                 B) Excessive muscle forces that
predispose to wear and breakdown of the teeth, gums, bone and the
tissues of the TMJ.1 In this article the methods of using Botulinum
Neurotoxin A as an adjunctive treatment used to control muscle
function that cause and contribute to disease are discussed.

 

The damage caused by excessive biting forces and dental trauma is
being treated with intra- oral appliances, occlusal adjustments,
sophisticated dental restorations and/or surgery. These are all
excellent treatment options but they are not for every patient. While
occlusion used to be regarded as the main cause of disease affecting
the masticatory system, muscular and psychological factors are as
important. Precise differentiation of the individual causal
etiological factors is generally not possible. The term Temporo
Mandibular Dysfunction is used to cover every disease affecting the
normal masticatory function. Unfortunately there is no common
treatment for every cause of TMD because it encompasses too many
different disease entities. These separate diseases have to be
isolated and then treated.

The dental profession has always prided itself in that the focus of
oral healthcare has been based on prevention. The focus of treatment
should be in the prevention and reduction of these destructive habits
Extra-capsular TMD is often transient and the least invasive treatment
options are usually best used to begin treatment. Orthognathic
surgery, orthodontics and a neuromuscular rehabilitation of the
occlusion are invasive, irreversible and expensive for the majority of
patients. There is no guarantee to the patient that these major
treatments will be effective. Sophisticated restorations are not only
very technique sensitive; they involve the removal of additional
healthy tooth material. The most esthetic, conservative restorations
may not withstand the forces applied to them. There is also a
reluctance to have perfectly healthy teeth prepared for ceramic or
gold restorations when the teeth are esthetically pleasing and
asymptomatic.

 

Intra-oral splints can be very effective in preventing excessive wear
and enabling the jaw to function in the most relaxed posture. Yet
there is a very low compliance with intra-oral splints and other
protective removable appliances worn over the teeth even when they are
effective. Patients do not like to have appliances in their mouths
impeding normal function like eating and speaking. Less than one in
five patients will wear a prescribed appliance as prescribed by their
treating dentist.

Many dentists have bleach trays and comfortable intra-oral devices for
their own mouths that they do not use as often as they should. Why
should our patients be any different?

 

The continued use of analgesics, narcotics, steroids and
anti-inflammatories for associated dento-facial symptoms is not ideal,
nor conducive to health. There are many unwarranted side-effects.
Certain patients like airline pilots, air-traffic control personnel,
surgeons, military personnel and anyone else operating heavy machine
equipment should not be taking narcotics. Yet patients will opt for
this despite the inherent risks and danger because of their ease of
use.

 

 

 

An extremely effective way to prevent damage and to enhance treatment
to dental hard tissue and restorations would be to de-program the
muscles responsible for excessive destructive forces and other
gnathalogically related diseases.

 
 THE NEW PARADIGM:
There is clearly a pronounced need to improve the options available
for preventive treatment of muscle generated dental disease, which
requires effective, safe agents that have minimal side effects, are
well-tolerated for long-term use, and that eliminate or reduce the
need to use other irreversible treatments or medications.
Intramuscular injections of Botulinum toxin type A (BTX-A) have been
increasingly used throughout the US as a novel approach to preventive
treatment that may provide effective, safe, and well-tolerated
long-term relief of intractable symptoms in patients who have failed
conventional approaches to treatment. The public does not yet
associate Botulinum neurotoxin A with their dentist but they very soon
and enthusiastically will. Dentists are skilled in the anatomy of the
lower facial anatomy and chewing apparatus. They are also prolific
injectors. Dentists have the advanced training in recognizing and
treating force related dental problems. This reduces the risk of
side-effects associated with unskilled injectors and injection
technique.

 

 
 
Background
Botulinum neurotoxins
There are seven botulinum neurotoxin serotypes (A, B, C, D, E, F, and
G), produced by Clostridium botulinum, all of which inhibit
acetylcholine release, though their intracellular target proteins, the
characteristics of their actions, and their potencies vary
substantially.2 At the neuromuscular junction, the inhibition of
acetylcholine release by BTX-A blocks or reduces contraction of
muscles, an effect which has been used therapeutically in disorders
characterized by overactive muscle activity such as cervical dystonia
(CD), blepharospasm,3,4 and spasticity.5

 

 

 

 

Botulinum toxin A (Botox) is the muscle relaxant that has been
popularized in the elimination of facial lines.6
Botulinum toxin type A (BOTOX®; Allergan, Inc.; Irvine, CA) is
currently approved for the treatment of blepharospasm, strabismus, and
CD.7 Binder and colleagues, treating patients for facial lines, noted
improvement of migraine symptoms after BTX-A injections.8 This
discovery led to further investigation in clinical trials of BTX-A
preventive treatment of migraine and other dento-facial diseases
including TMD.

Btx A has been proven to successfully eliminate or reduce excessive
clenching by de-sensitizing spindle cells within tense muscles, the
main cause of force related dental disease, when injected into the
chewing muscles. Parafunctional clenching to the extent that it
affects oral function causes damage to oral tissues is usually
transient. For this reason aggressive irreversible treatments should
be avoided. Particularly where compliance is a problem, Botulinum
toxin A (Botox) offers this option.

 

Preventative control of biting parafunctions and excessive forces on
the chewing apparatus will be the most significant paradigm in dental
treatment since local anesthetic and the dental drill. Dentists will
have the ability to reduce the need for major aggressive treatments
that involve surgery or drilling many teeth. "Surgical procedures that
alter anatomic relationships without addressing factors contributing
to pathogenesis may be more prone to failure and recurrence of [TMD]
symptoms. It is clear that excessive loading on articular tissues is
one of the causative factors that must be identified and addressed by
all clinicians treating patients with TMJ pathology” 2

The public does not yet associate Botulinum neurotoxin A with their
dentist but they very soon and enthusiastically will. Dentists are
skilled in the anatomy of the lower facial anatomy and chewing
apparatus. They are also prolific injectors. Dentists have the
advanced training in recognizing and treating force related dental
problems. They are also very familiar with facial anatomy. It will be
possible to teach dentists fairly easily how to treat their patients
with BTX A and how to avoid the major side-effects. These are caused
predominately by incorrect injection technique. This reduces the risk
of side-effects associated with unskilled injectors.

 

ADMINISTERING BTX-A FOR PREVENTIVE DENTALLY RELATED CONDITIONS
Patient selection:BTX-A therapy is appropriate for patients for whom
other preventive treatments and medications are poorly tolerated or
contraindicated, for those refractory to other treatments, for those
in special patient populations, as well as for those who simply prefer
this treatment. Contraindications to the use of BTX-A include
sensitivity to toxin or neuromuscular disorders such as myasthenia
gravis or Eaton-Lambert syndrome.

Pretreatment Procedures
Informed consent
Once an appropriate patient is selected for BTX-A treatment, the
dentist should set reasonable treatment goals. Patients should first
be told that the use of BTX-A as preventive treatment is off-label
use; that while there is clinical evidence to support its use as a
preventive agent, investigation is ongoing. Patients should also be
told that the optimal effects of BTX-A treatment may not be
experienced for at least 1 week and will begin to wear off after
approximately 3 months, and that multiple treatment cycles may be
needed to achieve an optimal therapeutic effect.22, 23 Galvez-Jimenez
N, Lampuri C, Patino-Piccirilo R, Hargreave M. Dystonia and headaches:
the response to botulinum toxin therapy. [Abstract] Cephalalgia. 2003;
23:760.

Blumenfeld A. Botulinum toxin type A as an effective prophylactic
treatment in primary headache disorders. Headache. 2003; 43:853-860.

 The known side effects of BTX-A treatment should also be made clear;
these include possible injection-site pain, headache, rash, bruising,
or ptosis. Informed consent should be obtained.
Identifying injection sites: Once treatment is ready to commence,
patients should indicate the anatomical locations of the head most
frequently affected by pain or muscles tender to touch. The treating
dentist should be able to identify the anatomical areas of tenderness
and sites that produce pain on palpation (including the frontalis,
temporalis, masseter, pterygoids, posterolateral neck and shoulder
regions) and examine the face and neck to assess symmetry.
Preparation of BTX for Injection
One neurotoxin type A (BOTOX®) and one type B (MYOBLOC®; Elan
Pharmaceuticals) are available in the United States. The majority of
the evidence has been based on using the type A toxin. Lyophilized
BTX-A, available in vials containing 100 U, should be diluted with 2
or 4 mL of preservative-free 0.9% saline, which yields a preparation
of 5.0 or 2.5 U per 0.1 mL, respectively. BTX Injection Sites
The injection sites commonly used for BTX-A treatment of dental
related conditions are the glabellar and frontal regions, the
temporalis muscle, the masseter, the depressor anguli oris, the
pterygoid muscles, and the cervical paraspinal region. Blumenfeld AM,
Binder W, Silberstein SD, Blitzer A. Procedures for administering
botulinum toxin type A for migraine and tension-type headache.
Headache. 2003; 43:884-891 Patients should be placed in a sitting or
supine position for injection of the frontal and temporal regions, and
a sitting position for injection of the posterior neck region and
trapezius. It appears most of the adverse events associated with BTX-A
injections are related to the technique and skill of the injector.
Correct injection technique helps minimize adverse events and optimize
treatment outcomes. The precise anatomical location, optimal choice of
injection site within a particular muscle, dosages, and volumes used
should all be considered carefully. Bilateral injections are advisable
in the case of unilateral headache or TMD pain as unilateral injection
can lead to the development of symptoms on the other side of the face.

Safety and Tolerability of BTX-A
BTX-A has an excellent safety and tolerability profile. There are
generally no systemic effects from treatment. The reported effects,
which are usually minimal and transient, include blepharoptosis
(droopy upper eyelid) and muscle weakness at injection sites.16 Evers
S, Rahmann A, Vollmer-Haase J, Husstedt I-W. Treatment of headache
with botulinum toxin A - a review according to evidence-based medicine
criteria. Cephalalgia. 2002; 22(9):699-710.

22,31 Silberstein S, Mathew N, Saper J, Jenkins S, for the BOTOX
Migraine Clinical Research Group. Botulinum toxin type A as a migraine
preventive treatment. Headache. 2000; 40:445-450.

 Proper injection techniques can minimize adverse effects such as
ptosis.29 Durham PL, Dacy R, Cady R. Regulation of calcitonin
gene-related peptide secretion from trigeminal nerve cells by
botulinum toxin type A: implications for migraine therapy. Headache.
2004;44:35-43.

 

Post injection Procedures
Instructions to patients
Patients should be informed that wheals or blebs at the injection
sites will disappear within approximately 2 hours. They should not
massage these wheals especially in the forehead as this may cause
ptosis. BTX-A–induced relief of headache and TMD symptoms may take
several weeks to reach its maximal benefit and the response to
injection may change over time. Patients should be informed that they
may achieve a greater therapeutic effect with repeated treatments.
Blumenfeld A. Botulinum toxin type A as an effective prophylactic
treatment in primary headache disorders. Headache. 2003;
43:853-860.Troost BT. Botulinum toxin type A (BOTOX®) in the treatment
of migraine and other headaches. Exp Rev Neurotherapeutics. 2004;
4:27-31.

 The effects of BTX-A injections wear off typically by 3 to 4 months
and repeat injections will be necessary.

Approaching insurers
BTX-A use for dental disease treatment is off-label. Discussion should
take place with insurers regarding reimbursement. An example of the
types of patients typically deemed appropriate for BTX-A preventive
treatment by insurers is given in the list below. To build a case that
a specific patient is suitable for BTX-A preventive treatment, a
letter explaining the need of specific patient to receive BTX-A
together with published clinical data will need to be sent to the
insurer.

 

Patients Typically Deemed Appropriate by Insurers for BTX-A Preventive
Treatment of Headache

Intractable migraine headaches and /or TMD at least twice a month
Chronic daily headaches of 15 headache days per month
Headache causing disability lasting three or more days
3 or more failed trials of at least 3 preventive pharmacological
therapies and other dental treatments with or without concomitant
behavioral and physical therapies
Abortive medications are required more than twice a week.
Abortive medications and treatment are contraindicated due to
coexisting medical conditions
The occupation or physical health of the patient contra-indicates
conventional treatment
 

 

POTENTIAL DENTAL USES
 The following are dental conditions that may be successfully treated
using Botulinum toxin A (Botox): Teeth, gum, cartilage and bone do
not regenerate, and, a full complement of teeth is essential for
overall health. Damage to these tissues can be prevented and the
success of reparative dental therapies can be predictably enhanced
using Botulinum toxin A (Botox)

 

 

 

Patients suffer from facial pain 4 caused by muscle spasm when the
relaxed posture of the mandible does not match the occlusion. This is
one of the many causes of Tempero Mandibular Disorder TMD. This pain
is exacerbated with parafunctional clenching (when the patient forces
their teeth for long periods of time for no apparent reason.) When
Botulinum toxin A (Botox) is injected into the muscles of mastication
and forehead, this clenching reflex (theoretically initiated by
sympathetically innervated spindle cells) is often eliminated.5, 6
This allows the muscles to relax appropriately and the pain dissipates
as the freeway space re-appears. The forces created by excessive
grinding and clenching of the teeth without food in the mouth are many
times greater those the forces required to masticate food. These
excessive forces damage the teeth, bone, joints and gums 7 Because a
very small percentage of available force is required to masticate
food, muscle function is not weakened sufficiently to have any effect
on chewing and swallowing.

 

 Tooth decay is more prevalent in clenchers because excessive forces
cause micro-fractures and abfracturing of enamel especially around
existing restorations. This may be followed by accelerated decay and
gingival recession.8

Botulinum toxin A (Botox) can be used to reduce these very common
dental conditions especially with patients who brux or clench
excessively while not being able to maintain ideal dental hygiene.

 

 

 

Excessive parafunctional forces created by clenching the jaws impede
healing and re-attachment of gum and bone in the mouth following
trauma. Low doses of Botulinum toxin will limit the parafunctional
clenching. Reduction in clenching intensity will allow traumatized
tissue to heal.

 

Higher doses can be used as a ‘pharmaceutical splint’ limiting muscle
contraction before resetting and during rehabilitation after fracture
of the facial bones e.g. when the condyle of the mandible is broken.

 

Parafunctional clenching contributes to periodontal trauma. Limiting
the clenching before and after periodontal surgery will benefit
healing. The use of a splint is often contra-indicated when the teeth
should be functional during healing. However with significant bone
loss excessive forces may jeopardize dental stability and contribute
to additional tooth loosening. The use of Botulinum toxin may be used
to control these potential destructive forces. The same applies in the
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.

 

Implant patients will benefit from pre-surgical Botulinum toxin A
(Botox). After multiple implants or immediate loaded implants are
placed osseo-integration can be prevented or impeded by excessive
functional and parafunctional forces. Overloading the implants results
in implant failure by loosening of the implant components or
prevention of osseo-integration. Nishimura, R. D., Beumer, J, 3rd,
Perri, G. R., Davodi, A. (1997) 9, 10, 11

 

 

Occlusal rehabilitation patients will benefit from Botulinum toxin A
(Botox). Botulinum toxin A can be used to verify that the correct
diagnosis has been made. This will also convince patients that their
toothache is muscular and not pulpal in origin. This should be done
before rushing into a major irreversible treatment "At best, we are
only managing signs and symptoms to the best of our ability within the
framework of the patient's ability to cope with the disorder” 12 The
best thing we can do for our clenching patients, then, is to help them
control parafunctional habits and thereby minimize the chances of
temporomandibular and dental complications.

 

Long-term temporization or a functional oral orthotic is used before
occlusal reconstruction to ensure that the treating dentist has
positioned the mandible comfortably reset the occlusion correctly and
that vertical dimension is maintained. Often the ideal position varies
vastly from the desired position in all three dimensions. These
prostheses will be better tolerated and the patient will be more
compliant with the use of Botulinum toxin A (Botox).

 

Orthodontic treatments on patients that are clenchers, have a deep
bite or crossed bite are prolonged if the vertical component of
muscular force is greater than the force of the fixed or removable
appliance. 13These cases often require the use of removable functional
retainers in combination with regular fixed braces in an attempt to
control the component of vertical force. Orthodontic treatment time
will be reduced and the patients will be far more comfortable and
functional (eating, speaking, swallowing) with the use of Botulinum
toxin A (Botox) especially if clenching is reduced.

 

An overactive genioglossus muscles protrudes the tongue between the
teeth while swallowing, referred to as a tongue thrust. The force of
the tongue prevents the front teeth from erupting into occlusion or
separates the teeth so that they don’t meet when the jaw closes. Low
doses of Botulinum toxin A (Botox) into these muscles will prevent a
tongue thrust and allow the teeth to erupt into occlusion. 14

 

 

Gummy smiles may be caused by over-contraction of the upper lip
muscles, obicularis oris and levator anguli oris. This cannot always
be corrected with osseous and gingival re-contouring. The upper lip
muscles can be proportionately weakened with Botulinum toxin A (Botox)
so as not to expose the upper gums when smiling. 15

 

Overactive depressor anguli oris muscles tend to give individuals a
sad or annoyed _expression weakening these muscles allows these
individuals to appear to have a happier disposition.

 

The depressor muscles of the lips together with an over closed
vertical dimension of the bite pulls the outer corners of the mouth
downwards and creates a deep skin fold or crease. Patients with
vitamin deficiencies and those that drool into these creases develop
angular cheilitis. Botulinum toxin A (Botox) can be used to weaken the
depressor muscles allowing the deep skin fold to disappear. The
elimination of this skin fold prevents saliva pooling and allows the
saliva to rapidly evaporate. This allows the skin to dry eliminating
the angular cheilitis caused by the prolonged moisture.

 

 

 The jaw closing muscles are much stronger than the jaw opening
muscles. When the closing muscles remain semi-contracted or in spasm,
mouth opening is limited.17

 

 This limits:

Oral hygiene: neither the patient, dentist or hygienist is able to
perform necessary hygiene to prevent oral disease

Dental treatment: necessary dental treatment including x-rays cannot
be done

Eating: the teeth cannot be separated sufficiently to bite an apple or
a sandwich

Kissing: passionate kissing is associated with a wide open mouth.

Shouting out loud: is difficult with limited opening

The mouth can usually open much wider when Botulinum toxin A (Botox)
is given into jaw closing muscles.

 

 

 

Patients who are chronic jaw clenchers present with masticatory muscle
hypertrophy. Overworked masseters tend to overdevelop causing the
cheeks to swell out. When Botulinum toxin A (Botox) is given into
these muscles, clenching is reduced and the enlarged masseters shrink.
18

 

 

Habitual clenchers are more prone to snoring and sleep apnea. When
Botulinum toxin A (Botox) is given into the masticatory muscles that
hold the jaw in a retruded position it enables the patients jaw to
move forward slightly during sleep. This will open the airway
sufficiently to reduce snoring.

 

There are probably many other indications that will develop over time.

 

 

 

 

 

 

 

THE MARKET POTENTIAL FOR THE DENTAL OFFICE

 

The use of Botulinum toxin A (Botox) in the dental office offers a
reversible alternative to the more aggressive procedures like full
mouth reconstruction, orthodontics and orthognathic surgery. It also
may offer an alternative to wearing an oral splint.22

 

Regular bi-annual visits had already fostered a trust between patients
and their dentist. With this trust relationship already in place,
patients will accept Botulinum toxin A (Botox) as they do accept their
bonding, braces and bleaching in the dental office. Many conditions
that contribute to TMD are successfully treated with Botulinum toxin A
(Botox) injections into the muscles of the forehead and masticatory
muscles.19 Dentists will be able to inject their patients with limited
additional training compared to their medical colleagues. Their
treatment time with the patient will be very productive because the
injections take a matter of minutes to perform. Dentists who elect to
use Botulinum toxin can schedule many patients requiring this form of
treatment on the same day. This eliminates wasting any expensive
unused Botulinum toxin A (Botox).

 

The Dental Boards of the majority of states will allow the use of
Botulinum toxin A (Botox) provided its usage (treatment of a dentally
related disease or condition) is covered by the their Dental Practice
Act. 20

 

When the dentist feels confident in the administration of Botulinum
toxin A (Botox) then the use of Botulinum toxin A (Botox) in the
dental office will surpass all other medical and cosmetic offices.
220 million Americans are already visiting their dental office
annually. We are living in the Age of Anxiety where 70% of the entire
population suffers from stress and grind their teeth, 75 % of the
entire population suffers from gum disease, 55% of the population
snores, 65% of the population requires braces, 15% of the population
require implants, the entire population wants their teeth to last a
lifetime and look younger.

 

As we enter the 21st century, the care of a rapidly aging population
may be the greatest challenge the dental profession will face in the
coming years, says the American Dental Association. More than 50,000
Americans per day are reaching the age of 50 years. By 2020, the
segment of the U.S. population aged 65 to 74 years is expected to grow
74 percent. The aging baby-boomers want to be functional, look good
and feel good.21 Many of these dental patients are already having
Botox cosmetic treatments elsewhere. It is important to space Botox
treatments at least 4 months apart for it to work effectively.
Headache, TMD, dental and cosmetic treatments involve injecting into
similar areas and therefore should be done for multiple benefits at
the same visit.

As a result the ability to make patients look younger will have
tremendous implications for the future of oral care. The dental
professional’s traditional role once centered around the eradication
of disease ... now finds itself on the threshold of enhancement of
appearance. This includes cavity reduction, educating the public about
the importance of good oral hygiene and the strides made toward
reducing the number of teeth lost to gum disease. In the mid 1990’s
dentistry changed from a needs based profession to a desired based
profession. Society realized that the youthful appearance of straight
white unworn teeth could be acquired only at their dental office. Most
dentists already consider themselves smile estheticians.

Society places an increasing priority on a healthy and attractive
smile, and as a result, the value of one's teeth has taken on a
greater importance. Advances in the area of cosmetic dentistry now
offer the dental profession new opportunities in restorative
procedures that have the potential to reverse the signs of dental
aging, thereby making patients look younger. The removal of healthy
enamel to place veneers is more invasive, problematic, irreversible
and technique sensitive then the use of BTX A will ever be.

.

 

 As the teeth are worn down or extracted the lower half of the face
collapses because there is no framework of teeth and bone to support
muscle and skin, the face looks tired, haggard and older. The cosmetic
surgeon can tighten the facial muscles and skin over a smaller face.
Only the dentist has the ability to repair and replace the worn down
and missing teeth so that the face retains its correct and true
proportion.21

 

The use of Botulinum toxin A (Botox) combined with a multitude of
health and cosmetically beneficial therapies will place the dentist in
a unique position to provide comprehensive functional and cosmetic
maintenance.

 

 

 

 

 

References:

Castaneda, R. (1992). Occlusion. In A. S. Kaplan & L. A. Assael (Eds).
2. Dolly O. Synaptic transmission: inhibition of neurotransmitter
release by botulinum toxins. Headache. 2003; 43(supp1):16-24.

3. Jankovic J, Brin MF. Therapeutic uses of botulinum toxin. N
Engl J Med. 1991;324:1186-1194.

      4. Naumann M, Yakovleff A, Durif F, BOTOX CD Prospective Study
Group. A randomized, double-masked, crossover comparison of the
efficacy and safety of botulinum toxin type A produced from the
original bulk toxin source and current bulk toxin source for the
treatment of CD. J Neurol. 2002; 249:57-63.

5. Brashear A, Gordon MF, Elovic E, et al, for the Botox
Post-Stroke Spasticity Study Group. Intramuscular injection of
botulinum toxin for the treatment of wrist and finger spasticity after
a stroke. N Engl J Med. 2002;347:395-400.

Temporomandibular Disorders (pp. 40-49). Philadelphia: Saunders.
(Israel, H. A., Diamond, B., Saed-Nejad, F., & Ratcliffe, A. (1999).
The relationship between parafunctional masticatory activity and
arthroscopically diagnosed temporomandibular joint pathology. Journal
of Oral and Maxillofacial Surgery, 57 (9), 1034-9.

7. Goadsby PJ, Lipton RB, Ferrari MD. Migraine—current
understanding and treatment.
N Engl J Med. 2002; 346:257-270.

8, Aesthetic Botulinum A Toxin in the Mid and Lower Face and Neck
.Jean Carruthers MD, Alastair Carruthers MD

Glaros, A. G. Tabacchi, K. N., & Glass, E. G. (1998). Effect of
parafunctional clenching on TMD pain. Journal of Orofacial Pain, 12,
145-152.

and hearing loss Bubon, M. S. (1995). Documented instance of restored
conductive hearing loss. Functional Orthodontist, 12, 26-9.

      5. Freund B, Schwartz M, Symington JM: The use of botulinum
toxin for the treatment of temporomandibular disorders: preliminary
findings. J Oral Maxillofacial Surgery 1999 Aug; 57(8): 916-20;
discussion 920-1

      6. Freund B, Schwartz M, Symington JM: Botulinum toxin: new
treatment for temporomandibular disorders. Br J Oral Maxillofacial
Surgery 2000 Oct; 38(5): 466-471.

      7. Christensen, G. J. (1999). Destruction of human teeth.
Journal of the American Dental Association, 130, 1229-30.

      8. Mcguire, M. K., & Nunn, M. E. (1996). Prognosis versus
actual outcome: III. The effectiveness of clinical parameters in
accurately predicting tooth survival. Journal of Periodontology, 67,
666-674.

      9. Implants in the partially edentulous patient: restorative
considerations. CDA Journal, 25, 867-871.

    10. Perl, M. L. (1994). Parafunctional habits, night guards, and
root form implants. Implant Dentistry, 3, 261-3.

11. Rangert, B., et al. (1995). Bending overload and implant
fracture. A retrospective clinical analysis. International Journal of
Oral Maxillofacial Implants, 10, 326-

    12. Pertes, Richard A. & Attanasio. Ronald (1992). Internal
Derangements. In Kaplan, A. S. and Assael, L. A.
Temporomandibular Disorders. Philadelphia: Saunders, pp. 142-164.

14. Tongue Protrusion Dystonia: Treatment With Botulinum Toxin P.
DAVID CHARLES, MD, THOMAS L. DAVIS, MD, KATHLEEN M. SHANNON, MD,
MATTHEW A. HOOK, BS, and JOHN S. WARNER, MD, Nashville, Tenn.

    15. Aesthetic Botulinum A Toxin in the Mid and Lower Face and
Neck
Jean Carruthers MD, Alastair Carruthers MD

16. Aesthetic Botulinum A Toxin in the Mid and Lower Face and Neck
Jean Carruthers MD, Alastair Carruthers MD

     17. Freund B, Schwartz M, Symington JM.

     J Oral Maxillofacial Surgery. 1999 Aug; 57(8):916-20; discussion
920-1.
  
 

The use of botulinum toxin for the treatment of temporomandibular
disorders: preliminary findings.

      18. Mandel, L. & Tharakan, M. (1999). Treatment of unilateral
masseteric hypertrophy with botulinum toxin: case report. Journal of
Oral and Maxillofacial Surgery, 57, 1017-1019.

     19. Freund B, Schwartz M, Symington JM: Botulinum toxin: new
treatment for temporomandibular disorders. Br J Oral Maxillofacial
Surgery 2000 Oct; 38(5): 466-471.

     20. "dentistry" means the diagnosis or management of conditions
of the mouth of a person, the performance of any invasive or
irreversible procedure on the natural teeth or the parts of a person's
body associated with their natural teeth or the provision to a patient
or the insertion or intraoral adjustment of artificial teeth or dental
appliances for a patient;

21. David Demko: Age trends create emphasis on Cosmetic Dentistry.
Senior World, Age Venture News Service

     

 22. H .Gobel et al. Botulinum Toxin A is effective in cases of
oromandibular dysfunction even if previous bite splint therapy has
proved unsuccessful. Cephalalgia 2001; 21(4):514-515 (1 Page).

 

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