REGISTRO DOI: 10.69849/revistaft/dt10202511181813
Anna Laira Malaquias Santiago
Abstract
This integrative review explores the applications of botulinum neurotoxin (BoNT) in dental practice, focusing on both its aesthetic use and its role in managing orofacial pain conditions. The mechanism of action of BoNT, which involves blocking acetylcholine release at the neuromuscular junction, leads to localized muscle relaxation. This effect provides a valuable therapeutic modality for a range of conditions, including excessive gingival display (gummy smile), a common aesthetic concern. Additionally, BoNT has proven effective in treating orofacial pain (OFP) conditions, such as bruxism and temporomandibular disorders (TMDs), by reducing muscle hyperactivity and modulating pain pathways. The review also discusses its emerging use for managing sialorrhea (excessive drooling) and neuropathic pain conditions like trigeminal neuralgia. While the effects are temporary, requiring repeat injections, BoNT represents a safe and effective, minimally invasive alternative for patients refractory to conventional treatments, signifying a notable evolution in modern dental care.
Keywords: Botulinum Toxin; Aesthetic Dentistry; Orofacial Pain; Bruxism; Temporomandibular Disorders (TMDs); Sialorrhea.
Botulinum neurotoxin (BoNT), a potent biological agent produced by the bacterium Clostridium botulinum, has garnered significant attention in dentistry beyond its traditional cosmetic uses. Its mechanism of action, which involves blocking the release of acetylcholine at the neuromuscular junction, leads to localized muscle relaxation. This effect, though temporary, provides a valuable therapeutic and aesthetic modality for a range of conditions within the oral and maxillofacial region. This integrative review explores the expanding applications of BoNT in dental practice, focusing on its efficacy in both aesthetic enhancements and the management of orofacial pain, supported by a growing body of academic literature.
The aesthetic application of BoNT in dentistry is most prominently recognized for the treatment of excessive gingival display, commonly known as a gummy smile. This condition, often caused by hyperactive levator labii superioris alaeque nasi muscles, can be effectively managed with precise injections of BoNT. Studies have demonstrated that this minimally invasive procedure can significantly reduce gingival exposure, leading to a more harmonious smile line and improved patient satisfaction (Mazzuco & Hexsel, 2010; Chagas et al., 2018). Furthermore, BoNT is employed to correct smile asymmetries and perioral rhytides, such as “smoker’s lines,” which can complement restorative and prosthetic dental work. The cosmetic use of BoNT in the dental setting is increasingly viewed as an adjunctive treatment that enhances the overall esthetic outcome of a patient’s smile makeover.
Beyond aesthetics, BoNT has emerged as a promising therapy for managing orofacial pain (OFP) conditions, particularly those of muscular origin. Bruxism, a parafunctional habit characterized by clenching and grinding, and temporomandibular disorders (TMDs) are two of the most significant applications. The injection of BoNT into the masticatory muscles, such as the masseter and temporalis, can reduce muscle hypertrophy and the excessive force generated during these parafunctional activities. Research has shown a reduction in pain intensity, headache frequency, and improved quality of life for patients with myogenous TMDs (Emara et al., 2013; Jadhao et al., 2017). While BoNT’s analgesic effect is partially attributed to muscle relaxation, some evidence suggests it may also have a direct effect on pain transmission pathways, independent of its motor function (Srivastava et al., 2015). This dual mechanism of action—reducing muscle hyperfunction and modulating pain perception—makes it a compelling option for patients who have not responded to conventional therapies like splint therapy or physical rehabilitation.
Recent research has also explored BoNT’s potential in salivary gland hyperfunction, a condition known as sialorrhea or excessive drooling. This can be particularly debilitating for patients with certain neurological conditions, such as Parkinson’s disease, or those who have had head and neck surgery. Injecting BoNT directly into the major salivary glands, such as the parotid and submandibular glands, can reduce salivary flow by inhibiting the release of acetylcholine, a key neurotransmitter in saliva production. This application offers a less invasive and often more effective alternative to surgical removal of the glands or daily use of anticholinergic medications, which can have significant systemic side effects. Studies in this area demonstrate a marked reduction in drooling and a notable improvement in the patient’s quality of life (Guarda-Nardini et al., 2012).
Furthermore, the application of BoNT is being investigated for its role in managing post-herpetic neuralgia affecting the trigeminal nerve and trigeminal neuralgia itself, two severe neuropathic pain conditions. While the primary treatment for these conditions is typically pharmacological, some patients remain refractory to conventional therapies. BoNT’s direct effect on pain transmission pathways is thought to be the mechanism by which it can reduce the excruciating, episodic pain associated with these conditions. Early studies and case reports suggest that BoNT injections into the trigger zones can provide significant pain relief, offering a new avenue for managing these complex pain syndromes (Srivastava et al., 2015). This highlights BoNT’s growing versatility beyond muscle-related issues to include direct modulation of nerve-related pain, further expanding its therapeutic scope in dentistry.
However, despite the documented successes, the use of BoNT in dentistry is not without its challenges. The transient nature of its effects, typically lasting 3 to 6 months, necessitates repeat injections, raising concerns about long-term costs and the development of immunogenicity (Jadhao et al., 2017). Furthermore, while studies have shown BoNT to be effective for managing the symptoms of bruxism, there is limited evidence to suggest it completely eliminates the underlying parafunctional activity itself (Srivastava et al., 2015; Sairat et el., 2020). The success of the treatment is also highly dependent on the skill of the operator, as proper dosage, injection site, and technique are critical to avoid complications such as muscle weakness, facial asymmetry, or dysphagia.
The flowchart illustrates the main applications of Botulinum Neurotoxin (BoNT) in dentistry, dividing them into two categories: aesthetic and therapeutic uses. On the aesthetic side, BoNT is employed to manage excessive gingival display, commonly known as a gummy smile, as well as smile asymmetries and perioral rhytides, enhancing overall dental esthetics. On the therapeutic side, BoNT is applied to treat orofacial pain conditions, including bruxism and temporomandibular disorders, in addition to managing sialorrhea and certain neuropathic pain conditions. This organization highlights BoNT’s dual role in improving both function and appearance in dental practice.
Figure 1. Flowchart of Aesthetic and Therapeutic Applications of Botulinum Neurotoxin (BoNT) in Dentistry.
In conclusion, the application of BoNT in dentistry represents a significant evolution in the field, offering safe and effective, minimally invasive alternatives for both cosmetic and therapeutic purposes. As a powerful tool for managing a variety of conditions, from gummy smiles to chronic orofacial pain, BoNT is becoming an integral part of the dental armamentarium. Continued research is essential to further standardize protocols, optimize dosing regimens, and explore the long-term outcomes and safety profile of this versatile neurotoxin.
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