STOMATOLOGY EDU JOURNAL 2017, Volume 4, Issue 3 SEJ_3-2017_Online - Page 52

Effective applications of botulinum toxin in dentistry and in head and neck surgery of the planned application, urinary tract infection, sphincter hypofunction and hypersensitivity to ingredients 3 to name just a few. Nowadays (March 2017), there are 372 known drugs that have minor or major contrainteractions with botulinum toxin and they need to be investigated and identified prior to the application so that the possibility of complications is reduced. They are known as the systemic adverse effects of botulinum toxin. Due to several fatal complications after high doses in neurology causing symptoms similar to those of poison botulism (none though attributed to cosmetic use) and many unpleasant side effects in aesthetic medicine, such as double vision, dysphagia, dry mouth or flu-like syndrome, 3 the US Food and Drug Administration (FDA) issued severe warning in 2009. Later on FDA approved revisions to the prescribing information to include mandatory boxed warning to ensure their continued safe use. 8 The duration of systemic complications may be in days but may last for several months. 9 It is important to be aware of these complications so that we can avoid them. And if the side effects appear it is crucial to know how to fix them, especially bearing in mind the risk of misuse by patients wishing to obtain financial compensation. Although botulinum toxin is one of the most interesting molecules with therapeutic benefits and has great significance in aesthetic medicine (before pushing surgical options) and has dozens of applications in curative medicine, the associated risks are recognised and evaluated prior each treatment. Therefore, only properly trained doctors and physicians shall be allowed to inject the botulinum toxin and should always respect the maximum recommended dose for the respective indications, as this drug could work as a dangerous poison. 3 4. Botulotoxin and dentistry The global market for the botulinum toxin is currently driven by its applications in aesthetic medicine. However, dentistry also has the potential to become one of the specialisations with top usage for some indications. In particular, the curative potential of this drug (outside the aesthetic medicine) is currently not fully deployed in Europe. With some minor exceptions, the use of the botulinum toxin is not yet part of an undergraduate programme, and we cannot find it even in the curriculum of medically oriented Maxillofacial Surgery. The fact that dentists may apply the botulinum toxin outside the oral cavity i.e in aesthetic medicine might sound controversial. On the contrary, dentists have the largest undergraduate training in the topographic anatomy of the head and neck. Even the new EU standardization, namely approved standard prEN 16884 on Aesthetic medicine services - Non-Surgical medical treatments does not include any restriction on the botulinum toxin application by dentists. It is essential in the future to meet the conditions of the national certification authority. Training on cadavers is considered to be the highest 202 quality standard education and has been carried out for several years in collaboration with the anatomical institutes around the world. Therefore, it is possible to obtain the necessary information of an appropriate quality level globally. 4.1. Curative indication 4.1.1. Headaches in region m. Occipitofrontalis The differential diagnosis of those pains has to be provided by a neurologist. But treatment is frequently done by an oral surgeon or maxillofacial surgeon due to their deep knowledge of the anatomy of the head and neck. The botulinum toxin is approved for the treatment of a chronic migraine, where it helps to reduce the excessive muscular tonus (in this manner it is also used in psychiatry), it also has a direct systemic reduction effect on migraine which provides an alternative non-cholinergic mechanism of action. 10 A successful therapy is subject to a complex differential diagnosis, where it is necessary to rule out other causes. A variety of pain in the head and neck should, therefore, be assessed by all specialists involved - a neurologist, an orthopedist, a spinal specialist, a-ENT specialist, a psychiatrist and last but not least, an oral surgeon. Pain in the frontal region is often projected from the temporomandibular joint. The author of this article has experienced cases where the primary cause of a patient treated with botulinum toxin was a dental problem in the upper jaw, complicated/accelerated by inflammation of the maxillary sinus, so the oral surgeon has to participate in this treatment. Sometimes the botulinum toxin is indicated for a migraine 11 elimination as a therapy experiment, where in case of initial failure “a long and uncomfortable diagnostic process” begins. Besides the frequent failure of the botulinum toxin effect on migraine reduction and related unnecessary financial costs, it is a risky procedure, especially for patients who are primarily psychiatrically ill. Due to the high incidence of pain projections in m. Occipitofrontalis (other than a migraine related), the implementation of such a therapy experiment is not very recommended and the decision on its indication shall be delegated to a neurologist (sometimes to a psychiatrist) subject to a thorough examination. The involvement of a psychiatrist is interesting also in the light of recent publications demonstrating the antidepressant effect of botulinum toxin 12 comparable with the most efficient antidepressants. It could be an interesting therapeutic option while providing an explanation for the addiction effect on the substance sometimes reported by some patients. 4.1.2. BTX as the solution for the facial asymmetry (hemifacial spasm, facial nerve palsy) It is one of the most interesting and also one of the most demanding applications. The face is always a little bit asymmetrical, but the &R&P6W'F&VF&W2gFV7V&V7FfVǒ'6W'fVB0V66WF&RF6&BFW6R7WG&W0&RW&6VfVB2W7FWF6ǒVFW6&&P6GVFB&vW"66R66FW&VB07FVGR#sB2##pGGwwr7FVGV6