Effectiveness of botulinum toxin B in the treatment of drooling

The aim of this audit was to assess the effectiveness of botulinum toxin B (NeuroBloc^®, Eisai Ltd.) in the treatment of drooling. Over a period of 18 months patients treated with NeuroBloc^® botulinum toxin (BTX) for serious drooling (drooling score more than 7) were invited to complete a questionnaire on their experience of drooling and the impact of treatment. A total of 170 questionnaires were given to consecutive patients or carers and 145 (85%) responded. Of these, 128 (88%) reported that symptoms had improved by 6/10 or more on a visual analogue scale (VAS), and 54 (37%) reported compete resolution of drooling (10/10 VAS). A total of 139 (96%) would recommend the treatment to others.     

Efficacy of botulinum toxins on bruxism: an evidence-based review

The objective of this study was to assess the efficacy of botulinum toxins on bruxism. Electronic databases (PubMed, Embase and Science Citation Index), websites (Cochrane Central Register of Controlled Trials and ClinicalTrials.gov) and the literature database of SIGLE (System for Information on Grey Literature in Europe) were searched from January 1990 to April 2011 for randomised controlled trials or nonrandomised studies assessing the efficacy of botulinum toxins on bruxism. There was no language restriction. Through a predefined search strategy, we retrieved 28 studies from PubMed, 94 from Embase, 60 from the Science Citation Index, two ongoing clinical trials and two from the Cochrane Central Register of Controlled Trials. Of these, only four studies met our inclusion criteria and were finally included. Of the four included studies, two were randomised controlled trials and two were controlled before-and-after studies. These studies showed that botulinum toxin injections can reduce the frequency of bruxism events, decrease bruxism-induced pain levels and satisfy patients' self-assessment with regard to the effectiveness of botulinum toxins on bruxism. In comparison with oral splint, botulinum toxins are equally effective on bruxism. Furthermore, botulinum toxin injections at a dosage of <100 U are safe for otherwise healthy patients. Botulinum toxin injections are effective on bruxism and are safe to use. Therefore, they can be used clinically for otherwise healthy patients with bruxism.     

Role of botulinum toxin A injection into the submandibular salivary glands as an assessment for the subsequent removal of the submandibular glands in the management of children with sialorrhoea

Sialorrhoea is caused by an excessive production of saliva or a lack of muscular coordination at the initiation of the swallowing reflex during the voluntary phase. In children with neuromuscular disorders it can cause excoriation and social embarrassment. In adults, repeated injections of botulinum have been shown to be beneficial in the control of sialorrhoea, but in children, lack of cooperation necessitates general anaesthesia, and repeated injections would not be appropriate. We aimed to assess outcome after injection of botulinum into the submandibular glands to find out whether subsequent removal of the glands would reduce salivary flow to an acceptable level. We assessed 30 children with various neuromuscular disorders that caused a lack of muscular coordination when swallowing. Under general anaesthesia, they all had injection of 1 unit/kg/gland of botulinum toxin A (Dysport™, Ipsen Ltd., Slough, UK) into each submandibular gland either by bimanual palpation or under ultrasound guidance. They were reassessed at 6 weeks to find out whether the flow had reduced adequately or whether the mouth was too dry. Twenty-one had improved and of these, 20 went on to have the glands removed successfully with no neurological or surgical complications. The mouth of one patient had become too dry after injection and the parents declined further surgery. The remaining 9 did not improve noticeably and continued to be managed medically.     

Botulinumtoxin zur Behandlung des gustatorischen Schwitzens

Background

Botulinum toxin A has meanwhile become a proven method for treatment of gustatory sweating (focal hyperhidrosis, Frey’s syndrome). Clear-cut recommendations regarding dosage of botulinum toxin A in Frey’s syndrome are currently not available. The aim of this prospective randomized study therefore was to investigate botulinum toxin A with respect to its efficacy in Frey’s syndrome, the ideal dose yielding maximal duration of the effect, and patient contentedness as well as unwanted side effects in patients of the Clinic of OMF Surgery at the Ruhr-University of Bochum.

Patients and method

Twenty patients suffering from severe Frey’s syndrome as a result of operations of the parotid gland were examined with the starch iodine test according to Minor. The gustatory skin areas were re-examined after intracutaneous injection of botulinum toxin A for up to 1 year. The patients (n=20) were randomly assigned to two different treatment groups (group I: 2 MU/cm², n=10; group II: 3 MU/cm², n=10).

Results

Mean sweating skin areas in the two treatment groups ranged between 39±9 and 32±12 cm², respectively. A single injection of 3 MU botulinum toxin A resulted in a nearly complete blockade of gustatory sweating for the observation period of 1 year. In the group treated with 2 MU botulinum toxin A, 44% of the total gustatory skin areas were still sweating, thus necessitating a second injection of botulinum toxin A in these patients.

Conclusion

Intracutaneous injection of botulinum toxin A represents a highly effective and minimally invasive procedure for the treatment of Frey’s syndrome. This study shows for the first time that a dosage of 3 MU/cm² of botulinum toxin A achieves a complete and reliable blockade of gustatory sweating lasting for at least 12 months. This dose may therefore be recommended for treatment of this syndrome.     

Effectiveness and safety of botulinum toxin in comparison with surgery for drooling in paediatric patients with neurological disorders: a systematic review

Different therapeutic methods for chronic drooling in paediatric patients with neurological problems have been described in the scientific literature. However, there is no consensus on the ideal strategy of treatment. The aim of this study was to compare botulinum toxin injection therapy and surgical modalities to control drooling in paediatric patients with neurological disorders. A systematic literature search was conducted on nine electronic databases for publications until April 2020. Six articles were included with a total sample of 209 patients, 67.4% (n = 141) of whom had cerebral palsy. All studies used injections of botulinum toxin type A with application to the submandibular and/or parotid salivary glands. The surgical treatments were duct ligation in the parotid and/or submandibular salivary glands, duct relocation in the submandibular salivary glands, and glandular excision of the submandibular and sublingual salivary glands. There were complications in only 16.1% (n = 27) of the sample (11 cases due to botulinum toxin application and 16 due to surgery). Drooling control was assessed by objective and subjective measures. Although surgical procedures presented a higher risk of adverse effects than botulinum toxin type A in all the studies and measurements performed, they presented larger and longer-lasting positive effects on drooling. We suggest bilateral submandibular duct relocation with bilateral sublingual gland excision or isolated bilateral submandibular duct ligation, which were the surgical techniques with the largest samples in this review. Nevertheless, further studies are necessary to compare samples with botulinum toxin type A and surgical treatment.     

The Use of Botulinum Toxin-A in the Treatment of Severe Bruxism in a Patient with Autism: A Case Report

This case report describes an alternative method for reducing bruxism in a special needs patient who was not a candidate for an intraoral appliance. Bruxism is often seen in patients with special needs and can result in excessive dental wear, temporomandibular joint pain, avulsion of teeth and other problems. Current methods of management are not typically effective in this population because most require patient compliance. An 11‐year‐old male diagnosed with autism and Bannayan‐Zonana syndrome received bilateral injections of botulinum toxin type‐A (Botox® Allergan Pharmaceuticals, Irvine CA) in the masseter muscle. The patient's condition was followed up via post‐operative telephone interviews with the parents for 60 days. A reduction in the frequency and severity of bruxism was reported. The only side effects noted were soreness at the injection site and mild, temporary drooling. Although further research is required to determine the optimal doses and injection frequency, botulinum toxin type‐A appears to be an alternative method for controlling bruxism in the special needs population.     

Efficacy of botulinum-A for nocturnal bruxism pain and the occurrence of bruxism events: a meta-analysis and systematic review

The purpose of this study was to explore the treatment efficacy of botulinum-A (BTX-A) in nocturnal bruxism. Five electronic databases (PubMed, Web of Science, Cochrane, Embase and Clinical Trials) were searched to identify related randomised controlled trials up to September 1, 2020. Five evaluation indices were extracted, namely, the pain at rest and at chewing (PR and PC), the number of bruxism events (NBE) and the self-assessment by patients (SA), to assess the treatment efficacy of BTX-A in bruxism. All data analyses were conducted using Review Manager (Version 5.3; The Cochrane Collaboration, London, United Kingdom). Six studies were included in this review. The sample was composed of 148 participants. Compared with the placebo group, the BTX-A group showed the significantly improved the PR index scores (MD, 1.16 cm; 95%CI, 0.65 to 1.67 cm; p < 0.00001), slightly improved the PC index scores (SMD, 0.25; 95%CI -0.14 to 0.64; p = 0.21), and the NBEs were significantly decreased in the before-injection group compared with that in the after-injection group (MD, 1.72; 95%CI, 0.60 to 2.85; p = 0.003). The results of this study suggest that BTX-A possesses significant therapeutic efficiency for the relief of pain and events of bruxism. However, whether the events of bruxism would recur or rebound after botulinum toxin injection needs more follow-up clinical evidence.     

Osteopenic consequences of botulinum toxin injections in the masticatory muscles: a pilot study

Patients with temporomandibular muscle and joint disorder (TMJD) increasingly seek and receive treatment for their pain with botulinum toxin (BoNTA; botulinum toxin A). Used intramuscularly in therapeutic doses, it produces localised paresis. Such paresis creates risk of reduced bone mineral density, or ‘disuse osteopenia’. Animal studies have frequently used BoNTA as a model of paralysis to induce bone changes within short periods. Osteopenic effects can be enduring in animals but have yet to be studied in humans. This is the first study in humans to examine bone‐related consequences of BoNTA injections in the masticatory muscles, comparing oral and maxillofacial radiologists’ ratings of trabecular bone patterns in the condyles of patients with TMJD exposed to multiple masticatory muscle injection sessions with BoNTA to a sample of patients with TMJD unexposed to masticatory muscle injections with BoNTA. Cone‐beam computed tomography (CBCT)‐derived images of bilateral condyles were evaluated in seven patients with TMJD receiving 2+ recent BoNTA treatment sessions for facial pain and nine demographically matched patients with TMJD not receiving BoNTA treatment. Two oral and maxillofacial radiologists evaluated CBCT images for evidence of trabecular changes consistent with osteopenia. Both evaluators noted decreased density in all participants exposed to BoNTA and in none of the unexposed participants (P < 0·001). No other abnormalities associated with reduced loading were detected. These findings need replication in a larger sample and over a longer time period, to ensure safety of patients with TMJD receiving multiple BoNTA injections for their pain.     

Type A botulinum toxin in the treatment of chronic facial pain associated with masticatory hyperactivity.

PURPOSE: Chronic hyperactivity of the masticatory muscles is a common functional disorder associated with chronic facial pain and headache. The positive therapeutic effect of botulinum toxin type A on functional disorders and pain symptoms has been known in connection with the treatment of cervical dystonia. The purpose of this report is to assess whether the targeted reduction of masticatory muscular hyperactivity by local injection treatment with botulinum toxin type A can improve facial pain headache symptoms in the event that other treatment methods prove ineffective. Materials and Methods: In an randomized blinded placebo-controlled study, 90 patients (60 verum and 30 placebo) with chronic facial pain were treated with botulinum toxin type A (Botox; Allergan, Ettlingen, Germany) injections into masticatory muscles. RESULTS: Ninety-one percent of patients who received botulinum toxin improved by a significant mean reduction of approximately 3.2 on a visual analog pain scale. By comparison with t test and chi(2) test, there was a significant difference compared with the placebo group (P <.01). CONCLUSIONS: The local injection of botulinum toxin type A constitutes an innovative and adequately efficient treatment method for chronic facial pain associated with hyperactivity of the masticatory muscles. An improvement in the painful symptoms can be expected in up to 90% of patients who do not respond to conservative treatment methods.     

Botulinum toxin for the treatment of bruxism

Aims: Botulinum toxin, the most potent biological toxin, has been shown to be effective for a variety of disorders in several medical conditions, when used both therapeutically and cosmetically. In recent years, there has been a rising trend in the use of this pharmacological agent to control bruxing activity, despite its reported adverse effects. The aim of this review was to provide a brief overview to clarify the underlying essential ideas for the use of botulinum toxin in bruxism based on available scientific papers.

Methodology: An electronic literature search was performed to identify publications related to botulinum toxin and its use for bruxism in PubMed. Hand searching of relevant articles was also made to identify additional studies.

Results: Of the eleven identified studies, only two were randomized controlled trials, compared with the effectiveness of botulinum toxins on the reduction in the frequency of bruxism events and myofascial pain after injection. The authors of these studies concluded that botulinum toxin could be used as an effective treatment for reducing nocturnal bruxism and myofascial pain in patients with bruxism.

Conclusion: Evidence-based research was limited on this topic. More randomized controlled studies are needed to confirm that botulinum toxin is safe and reliable for routine clinical use in bruxism.     

Botulinum toxin treatment of salivary fistulas following parotidectomy: follow-up results

Background

Salivary fistulas are a well-known sequel of parotidectomy, and successful treatment with botulinum toxin has been demonstrated in individual cases. Here, we report on 12 patients with fistulas treated following parotidectomy for various indications.

Methods and results

Injection of botulinum toxin type A into the residual gland tissue was the initial treatment. After early intervention (within 6 weeks after development of the fistula), only one fistula remained (9 of 10 fistulas treated early only with botulinum toxin). One patient with early intervention did not want to wait for the botulinum toxin treatment to take effect and demanded early surgical revision, which was successful. In one patient with a permanent fistula, botulinum toxin treatment began 420 days after the operation and was unsuccessful. No side effects were evident after the treatment.

Conclusion

In summary, botulinum toxin injections into the parotid tissue remaining after surgery appear to be an effective treatment for salivary fistulas following parotidectomy.     

A型肉毒素对下颌骨发育的早期干预实验研究

目的:探讨咬肌注射A型肉毒素后对于下颌骨早期过度发育的干预影响。方法:3周龄SD雌性大鼠35只,体重60~80 g,随机取5只大鼠咬肌不作任何处理作为正常对照组(组1),随机取5只大鼠第4周时双侧咬肌注射花生油(癸酸诺龙溶剂)作为阴性对照组(组2),另25只大鼠进行A型肉毒素干预下颌骨发育实验。实验组25只大鼠分为5组(组3~组7),每组每周于双侧咬肌注射癸酸诺龙,其中4组(组4~组7)分别于4、5、6、7周进行干预,于双侧咬肌注射A型肉毒素1次,共2 U,7组35只动物于15周龄时取材,下颌骨进行Mirco-CT扫描,经软件重建三维模型后测量标志点进行分析。结果:标志点测量后,组3与组1和组2之间各项指标差异有显著性。组4、5、6、7各项指标与组1接近,与组3差异有显著性,各项指标均有减小,组1与组2各项指标差异无显著性。组5指标与组3差异具代表性。结论:大鼠青春期前咬肌注射癸酸诺龙可以使大鼠下颌骨在长度和高度上过度发育,咬肌注射A型肉毒素可早期干预大鼠下颌骨过度生长发育。大鼠5周龄时A型肉毒素干预最有效果。     

Role of medical thermography in treatment of Frey's syndrome with botulinum toxin A

Frey syndrome classically causes gustatory sweating and facial flushing. We describe 2 cases in which medical thermography was used to investigate the symptoms. Images were taken after patients chewed a sialagogue and 2 weeks later they were given injections of botulinum toxin A. Images taken 4 weeks after treatment showed a considerable reduction in sweating and facial flushing, which was supported by the results of quality of life questionnaires completed before and after treatment. Medical thermography is much cleaner than the Minor's starch iodine test. It identifies areas of gustatory sweating, changes in temperature, and vascular changes, which potentially enable treatment to be targeted accurately.     

Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique

A randomized controlled trial was performed to compare the short-term effectiveness of botulinum toxin injections and physiatric treatment provided by means of Fascial Manipulation techniques in the management of myofascial pain of jaw muscles. Thirty patients with a Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) diagnosis of myofascial pain were randomized to receive either single-session botulinum toxin injections (Group A) or multiple-session Fascial Manipulation (Group B). Maximum pain levels (VAS ratings) and jaw range of motion in millimeters (maximum mouth opening, protrusion, right and left laterotrusion) were assessed at baseline, at the end of treatment, and at a three-month follow-up. Both treatment protocols provided significant improvement over time for pain symptoms. The two treatments seem to be almost equally effective, Fascial Manipulation being slightly superior to reduce subjective pain perception, and botulinum toxin injections being slightly superior to increase jaw range of motion. Differences between the two treatment protocols as to changes in the outcome parameters at the three-months follow-up were not relevant clinically. Findings from the present investigation are in line with literature data supporting the effectiveness of a wide spectrum of conservative treatment approaches to myofascial pain of the jaw muscles. Future studies on larger samples over a longer follow-up span are needed on the way to identify tailored treatment strategies.     

Treatment of perioral dystonia with botulinum toxin in 4 cases of Meige's syndrome

OBJECTIVE: We describe the treatment of 4 patients (median age, 53.5 years) with incapacitating perioral dystonia and insufficient response to peroral medication. Their general treatment with clonazepam and anticholinergics was supplemented by intramuscular injections with botulinum toxin A (20-40 U) in the orbicularis oris muscle, guided by electromyography (EMG). STUDY DESIGN: Perioral dystonia and treatment effect were assessed by using subjective global and visual analog scales, examiner-based video movement counts and rating scales, and quantitative EMG. t Tests were used for statistical analysis. RESULTS: The result of the intramuscular botulinum toxin A injections was characterized by the patients as "much improved"; correspondingly, dystonia was significantly reduced in visual analog scale scores, on examiner-based assessments, and in recordings of EMG. The side effects were few and short-lasting. CONCLUSION: Incapacitating perioral dystonia in Meige's syndrome may be safely controlled by recurrent EMG-guided botulinum toxin A injections in the orbicularis oris muscle, in combination with general medication.     

Botulinum toxin for ductal stenosis and fistulas of the main salivary glands

This study was performed to present the authors’ experience with botulinum toxin therapy for salivary stenosis and salivary fistula in terms of the procedure, dosage, effectiveness, and complications. A retrospective study of all patients treated in the maxillofacial surgery department for salivary stenosis or fistula from January 2014 to September 2018 was performed. Intraglandular injections of incobotulinumtoxinA (Xeomin) were utilized. The frequency of relapse and the pain recorded before injection and at 3 months after each injection or fistula resolution were assessed. Swallowing dysfunction or any diffusion of toxin into the facial muscles was recorded. This study included 22 patients (mean age 53 years). Botulinum therapy was indicated for parotid duct stenosis in 14 patients, submandibular duct stenosis in four patients, and parotid fistula in four patients. The frequency of relapse (P = 0.0001) and pain level (P = 0.0001) decreased after botulinum therapy. The average duration of the botulinum effect was 4.50±2.00 months after the first injection. No complication was observed. Botulinum therapy with 100 IU of Xeomin proved effective at resolving salivary fistula. Botulinum therapy is an effective treatment for symptoms of salivary duct stenosis in patients for whom minimally invasive procedures have failed. Botulinum therapy can also be used for the treatment of salivary fistulas.     

Surgical management of persistent oromandibular dystonia of the temporalis muscle

A rare case of unifocal oromandibular dystonia of the temporalis muscle is presented. It was treated with surgical myotomy when initial botulinum toxin A therapy failed after 3 years of repeated injections.     

Botulinum toxin in the management of temporomandibular disorders: a systematic review

The aim of this review was to critically investigate and assess the evidence relating to the use and efficacy of botulinum toxin (BTX) in the management of temporomandibular joint disorders (TMD) and masticatory myofascial pain. A comprehensive search was conducted of PubMed, Scopus, Embase, and Cochrane CENTRAL, to find relevant studies from the last 30 years up to the end of July 2018. Seven were identified. Three showed a significant reduction in pain between the BTX and placebo groups and one showed a clinical, but not a significant, difference. In one that compared BTX with another novel treatment, myofascial pain reduced equally in both groups, and in the remaining two there was no significant difference in pain reduction between the BTX and control groups. Of the four studies that assessed mouth opening, two reported that BTX had resulted in a slight improvement; one reported no improvement, and the other a worsening of the condition. A meta-analysis was not possible because of the considerable variation in the studies’ designs, the heterogeneity between the groups, and the different assessment tools used. Despite showing benefits, consensus on the therapeutic benefit of BTX in the management of myofascial TMD is lacking. Further randomised controlled trials with larger sample sizes, minimal bias, and longer follow-up periods are now needed.     

Treatment of recurrent dislocation of the temporomandibular joint with type A botulinum toxin

A case is reported of a 56-year-old woman who suffered from recurrent dislocations of the temporomandibular joint (TMJ) secondary to an exacerbated tetraspastic syndrome of multiple sclerosis. Following chemical denervation of the masseter and pterygoid muscles with injections of type A botulinum toxin, no further dislocations occurred for periods of up to four months. The treatment has been repeated five times. Some of the indications and possible adverse reactions to this therapy are discussed and comparisons made with other, conventional methods for managing recurrent dislocation of the TMJ.     

Frey-Syndrom nach lateraler Parotidektomie

Background: Gustatory sweating is a common complication of parotid surgery.¶Patients and methods: In order to evaluate the incidence of Frey’s syndrome following superficial parotidectomy, 69 patients who underwent surgery due to adenoma were studied. Forty-three patients (62%) suffered from gustatory sweating following superficial parotidectomy, and 33 of them requested treatment. Nineteen patients felt that their quality of life had been decreased by the symptoms. Results: Minor’s starch iodine test proved that 85% of the patients who did not notice Frey’s syndrome after surgery actually had a subclinical manifestation. Eight patients were successfully treated with intracutaneous injections of botulinum toxin A. Within 1 week gustatory sweating disappeared. Conclusion: Frey’s syndrome is present in almost all patients following superficial parotidectomy and there is a strong need for treatment. Intracutaneous injection of botulinum toxin A is an effective treatment in severe cases of the syndrome.