Botox and Parkinson dystonia

[Smilemaker100]

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I am back. Yes, the dentist, again. 😀

I have read a whole slew of fascinating articles in regards to the management of clenching in those afflicted with Parkinson 's. I was particularly interested in some recent studies which included case reports in which Botox was administered for the treatment of the following conditions : orofacial pain, TMJ disorders,bruxism (clenching) and oromandibular disorders.

A bit of history on my Parkinson's patient:

The patient is a 64 year old Caucasian male who was diagnosed with Parkinson's disease in 1997 after he noticed resting tremors. He does not have a history of any other illness. The patient is presently taking sinemet (he has recently stopped this med because it is not effective as it used to be ), amantidine and apokyn.

His present symptomology is as follows: bradykinesia,mild akinesia
dyskinesia (mainly at the level of the hands) and oromandibular dystonia.

The patient has complained to his neurologist about a diurnal clenching problem. He exhibits general wear of his dentition. He also is not able to open his mouth maximally (trismus) . A mouth guard has been proposed for him but he is not interested.

I have spoken to the patient about discussing pharmacological management of his dystonia with his neurologist and cited Botox as a possibility (injected into the masseters, lateral pterygoid muscles). He will be seeing his neurologist next week and I will be doing a follow up with his doctor.

How many of you know of neurologists who administer Botox for the indications above? Opinions?

Thanks 🙂

 

[neurologist]

I am back. Yes, the dentist, again. 😀

I have read a whole slew of fascinating articles in regards to the management of clenching in those afflicted with Parkinson 's. I was particularly interested in some recent studies which included case reports in which Botox was administered for the treatment of the following conditions : orofacial pain, TMJ disorders,bruxism (clenching) and oromandibular disorders.

A bit of history on my Parkinson's patient:

The patient is a 64 year old Caucasian male who was diagnosed with Parkinson's disease in 1997 after he noticed resting tremors. He does not have a history of any other illness. The patient is presently taking sinemet (he has recently stopped this med because it is not effective as it used to be ), amantidine and apokyn.

His present symptomology is as follows: bradykinesia,mild akinesia
dyskinesia (mainly at the level of the hands) and oromandibular dystonia.

The patient has complained to his neurologist about a diurnal clenching problem. He exhibits general wear of his dentition. He also is not able to open his mouth maximally (trismus) . A mouth guard has been proposed for him but he is not interested.

I have spoken to the patient about discussing pharmacological management of his dystonia with his neurologist and cited Botox as a possibility (injected into the masseters, lateral pterygoid muscles). He will be seeing his neurologist next week and I will be doing a follow up with his doctor.

How many of you know of neurologists who administer Botox for the indications above? Opinions?

Thanks 🙂

I've used it successfully in a couple of TMJ patients, and numerous hemifacial spasm/blepharospasm patients. For TMJ, I use 60-80 units of BotA in the bilateral temporalis and masseters. Would probably be worth a try in this patient.

 

[Smilemaker100]

I've used it successfully in a couple of TMJ patients, and numerous hemifacial spasm/blepharospasm patients. For TMJ, I use 60-80 units of BotA in the bilateral temporalis and masseters. Would probably be worth a try in this patient.

Thanks, neurologist. 🙂 I have read that EMG localization is used to target the appropriate masticatory muscles when administering Botox for oromandibular dystonias. Ultrasound is used as well in some cases. Did you use EMG or ultrasound to administer the BotA in the temporalis and masseters?

I wasn't sure if many neurologists have ventured in this treatment option for movement disorders. From what I understand ,oral maxillofacial surgeons and plastic surgeons are qualified to administer Botox. I was amazed at all the indications for Botox which I read about in the literature.

I'll be contacting the patient's neurologist next week to obtain an accurate history of the pharmacological management of this patient’s illness as well as any associated symptoms which were manifested in the head and neck area.
What sort of questions would be relevant to ask my patient's neurologist?

I feel a rush of excitement about this case! 😀 Monetarily speaking , I won't win anything from this whole project but that doesn't matter. What matters is that I will be improving the quality of life for this patient 🙂 and I may produce a short article from this case.

I love the interdisciplinary aspect which seems to be an increasing trend in all of the health fields. I love what I do. 😍

I really would appreciate input from other neurologists/residents in this forum. 👍 Thanks.

References:
1) Munchau. A , Bhatia, K.P. Use of botulinum toxin injection in medicine today BMJ 2000;320: 161-165
2) Jankovic J, Brin MF. Therapeutic uses of botulinum toxin. N Engl J Med 1991; 324:1186-94.
3) Panikar, JN, Muthan UB. Botulism toxins: Pharmacology and its current therapeutic evidence for use. Neurol India 2003; 51:455-460.
4)Tan E-K, Jankovic J. Treating bruxism with botulinum toxin. JADA 2000;131:211-216.
5) Magee KR. Bruxism related to levodopa therapy. JAMA 1970;214(1):147
6)Jankovic J, Schwartz K, Donovan DT. Botulinum toxin treatment of cranial-cervical dystonia, spasmodic dysphonia,other focal dystonias and hemifacial spasm. J Neurol Neurosurg Psychiatry 1990;53(8):633-9.
7) Training guidelines for the use of botulinum toxin for the treatment of neurologic disorders:report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 1994;44 (12):2401-3.
8)Watts MW, Tan E-K, Jankovic J. Bruxism and Cranial –Cervical Dystonia: Is there a relationship? J Craniomand Practice 1999; 17(3): 196-201.
9)Robertson LE, Hammerstad JP. Jaw movement dysfunction related to Parkinson’s disease and partially modified by levodopa. J Neurol Neurosurg Psychiatry 1996;60:41-50.
10)Blitzer A, Greene PE, Mitchell BF, Blitzer A, Fahn S. Botulinum toxin injection for the treatment of oromandibular dystonia. Ann Otol Rhinol Laryngol 1989;98:93-97.
11)Karlsson S, Persson M,Johnels B. Levodopa induced ON-OFF motor fluctuations in Parkinson's disease related to rhythmical masticatory jaw movements. J Neurol Neurosurg and Psych 1992; 5:304-307
12) Minagi S, Matsunaga T, Shibata T, Sato T. An appliance for management of TMJ pain as a complication of Parkinson’s disease. J Craniomand Practice 1998;16 (1) :57-59.
13) Durham TM, Hodges ED, Mitchell JH, Geasland J, Straub P. Management of orofacial manifestations of Parkinson’s disease with splint therapy: a case report. Spec Care Dent 1993;13(4): 155-158.
14) Sacks OW, Ross SJ, DePaola DP, Kohl MS. Abnormal mouth-movements and oral damage associated with L-dopa treatment. Ann Dent 1970; 29:130-144.
15) Schneider JS, Diamond SG, Markham CH. Deficits in orofacial sensorimotor function in Parkinson’s disease. Ann Neurol 1986;19:275-282
16)Abbs JH, Hartman DE, Vishwanat B. Orofacial motor control impairment in Parkinson’s disease. Neurology 1987;37:394-398.
17)Collins R. Special considerations for the dental patient with Parkinson's disease. Tex Dent J 1990;107(3):31-33
18)Jolly DE, Paulson RB, Paulson GW, Pike JA. Parkinson's disease:a review and recommendations for dental management. Spec Care Dent 1989;9 :74-78.

 

[neurologist]

Thanks, neurologist. 🙂 I have read that EMG localization is used to target the appropriate masticatory muscles when administering Botox for oromandibular dystonias. Ultrasound is used as well in some cases. Did you use EMG or ultrasound to administer the BotA in the temporalis and masseters?

I wasn't sure if many neurologists have ventured in this treatment option for movement disorders. From what I understand ,oral maxillofacial surgeons and plastic surgeons are qualified to administer Botox. I was amazed at all the indications for Botox which I read about in the literature.

I'll be contacting the patient's neurologist next week to obtain an accurate history of the pharmacological management of this patient’s illness as well as any associated symptoms which were manifested in the head and neck area.
What sort of questions would be relevant to ask my patient's neurologist?

I feel a rush of excitement about this case! 😀 Monetarily speaking , I won't win anything from this whole project but that doesn't matter. What matters is that I will be improving the quality of life for this patient 🙂 and I may produce a short article from this case.

I love the interdisciplinary aspect which seems to be an increasing trend in all of the health fields. I love what I do. 😍

I really would appreciate input from other neurologists/residents in this forum. 👍 Thanks.

Neurologists have been using botox for movement disorders and spasticity for quite a while. The newest use is migraine prophylaxis. Quite a few neurologists are using it; it's not hard and it can really improve the patient's quality of life.
I used EMG for my TMJ patients, but I don't necessarily use it in every other patient.
There are few real contraindications for its use. I would specifically inquire about whether your patient has any speech, chewing or swallowing problems, all of which may be worsened by weakening the masticatory muscles (at least for awhile -- the nice thing about botox in this regard is that it wears off after a while).

 

[Smilemaker100]

Neurologists have been using botox for movement disorders and spasticity for quite a while. The newest use is migraine prophylaxis. Quite a few neurologists are using it; it's not hard and it can really improve the patient's quality of life.
I used EMG for my TMJ patients, but I don't necessarily use it in every other patient.
There are few real contraindications for its use. I would specifically inquire about whether your patient has any speech, chewing or swallowing problems, all of which may be worsened by weakening the masticatory muscles (at least for awhile -- the nice thing about botox in this regard is that it wears off after a while).

Thanks, again, neurologist.

I have also read that botox is being used for myofascial pain and other chronic pain conditions which is of particular relevance in dentistry (eg.trigeminal neuralgias).

The patient exhibited a bit of hypernasality and dysphasia so there may be some laryngeal involvement. I don't know this patient very well as I have only seen him on two occasions. I'll have to ask his neurologist for a better physical assessment.

I just read something interesting in regards to the orofacial motor control impairement in PD:

"In view of the special anatomic and physiologic characteristics of the orofacial system, and apparently a unique interrelationship with the basal ganglia, orofacial motor impairments in PD are likely to be different from those manifest in the extremities. As such, orofacial movement disorders with PD may not respond to drug manipulation in the same way as the muscle groups of the extremities. The present study thus suggests that PD treatment results in the limb and the orofacial muscle groups should be evaluated separately." Ref. #16

 

[Molly Maquire]

What type of reimbusment you get for these Botox injections?

 

[Smilemaker100]

What type of reimbusment you get for these Botox injections?

Don't know how much the neurologist will get, but I get nada .