Since it stormed onto the scene by way of high-end Hollywood parties in the 1990s, Botox has undergone an almost meteoric rise in the healthcare field. Much more than a wrinkle-reducer for the rich and famous, botulinum toxin today provides relief for patients suffering from migraines and excessive sweating to twitchy eyes and leaky bladders.
Its medical uses actually took root long before Botox became a cosmetic tool, smoothing forehead lines and fueling frozen-face jokes. In the 1970s, an ophthalmologist seeking non-surgical solutions for his patients with crossed eyes (strabismus) uncovered the toxin’s therapeutic benefit.
Alan Scott, MD, died in 2021, but not before "the father of Botox" saw his work result in the first Food and Drug Administration (FDA) approval of the therapy for crossed eyes and eye twitching (blepharospasm) in 1989 and shake up the cosmetic world. Today, numerous brands beyond the original Botox are used to treat a wide range of medical issues.
“In medicine, when things have to be researched as well as they do, they often move beyond their initial intended purposes,” said Kyle Diehl, PhD, DDS, MSD, an assistant professor in the CU School of Dental Medicine, who uses botulinum toxin in his private practice. “It’s able to be utilized in other spaces once the mechanism of how it works is understood.”
A highly deadly poison once studied by the U.S. military for biological warfare, botulinum toxin prevents the release of the neurotransmitter acetylcholine.
“Very simply, it blocks the signal between the nerve and the muscle at the neuromuscular junction,” said Sana Aslam, DO, assistant professor of neurology at the University of Colorado School of Medicine. “So, it’s not changing anything in the brain. It’s not changing anything in the nerve. It’s just not letting the nerve and muscle communicate as effectively.”
The neurotoxin, produced by the bacterium Clostridium botulinum, was best known before its wrinkle-erasing heyday for causing botulism, an illness often associated with honey and infants and improperly home-canned foods.
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Botulinum toxin brands have expanded beyond Botox. Doctors use other brands, including: Dysport; Xeomin; Jeuveau; and Daxxify.
Left untreated, botulism kills by paralyzing respiratory muscles. That muscle-immobilizing action – when harnessed in purified, minute doses and targeted by well-trained providers –can have untold therapeutic effects on the human body, with its over 600 muscles that all play vital roles.
With the injections, misbehaving muscles are basically put in timeout. By blocking contractions of the targeted muscles, forehead wrinkles diminish, neck spasms cease and tight jaws relax.
“It might not necessarily be solving the issue, but it dampens down the effects,” said Diehl, explaining the therapy’s use for dental conditions such as teeth grinding (bruxism) and temporomandibular disorders (TMDs).
With TMDs, over-active muscles surrounding the jaw joint cause pain and dysfunction. Targeting those muscles with botulinum toxin can release tension, relieve pain and allow muscles to rest.
“With the overactive usage, those muscles get stronger and really hardy,” Diehl said. “This can help bring things back down while you are utilizing other therapies. And I think there is utility in removing pain for people.”
As with many current uses, dental applications for botulinum toxin therapy are provided “off label,” as doctors may use approved products for conditions not yet given the FDA nod. But off-label use generally means no insurance coverage, which can result in significant out-of-pocket expense for a therapy that is only temporary.
“The good and the bad thing about Botox is that it wears off,” Aslam said. “It’s good because if you have side effects, it will wear off; your body metabolizes botulinum toxin. It’s bad because you have to come in and have the injections about every three months.”
As formulations continue to improve, Aslam and her colleagues at the CU Movement Disorders Center on the CU Anschutz Medical Campus hope eventually to see products become longer-lasting.
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A few approved conditions for botulinum therapy:
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A few off-label conditions for botulinum therapy:
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“Every three months is rough for people,” Aslam said. “For some people, it is a deterrent from getting Botox, especially younger people who are working full time.” The therapy, done in the outpatient clinic setting, can also take up to two weeks to take effect.
A majority of the medical conditions for which botulinum toxin has been approved land in the neurology and movement disorder realm, Aslam said, with dystonia and spasticity two chief disorders she treats with the injections.
Spasticity, a condition that can be associated with disorders such as cerebral palsy and multiple sclerosis, results in abnormal muscle tightness due to prolonged contraction.
The therapy is also FDA-approved for cervical dystonia, which causes painful involuntary muscle contractions of the neck, resulting in abnormal postures and repetitive movements.
Dystonia can affect a single muscle, a group of muscles or all of the muscles in the body in a generalized form. “It can be the arm, leg or even voice,” Aslam said. Some medications can cause dystonia, and there are task-specific types, such as musician’s dystonia or writer’s cramp. “Muscles will posture, cramp and pull only when you are doing these certain tasks.”
A growing supply of new botulinum toxin brands helps improve patient care, Aslam said. “Someone may not respond to one type, so we may switch to a different one and see if it works better.”
Although formulations have been changed, reducing the problem, people who have gotten botulism toxin for many years might develop antibodies, Aslam said. “If it feels like it stopped working, it might be that your body’s developed a resistance, and then we can sometimes try a different brand or subtype of toxin.”
Patients sometimes opt for the therapy over other medications for their condition because they like the more localized approach with botulinum toxin injections, Aslam said. “Sometimes it’s nice, because then you are just treating the symptom.”
To prevent side effects and improve success, patients should make sure providers are well-trained in the procedure and specialize in the area being treated. “Don’t be afraid to ask,” Diehl said. “Where did you go to school? Did you do postgraduate training? Are you a specialist? I think it’s fine for patients to ask what training providers have.”
The therapy is generally considered safe long term, and there have been patients on it for years, Aslam said. “Side effects can include bruising from the needle, risk of infection and muscle weakness, if a dose is just a little too high or if it’s not quite the right muscle.”
Although rare in the right hands, there can be nerve damage, Diehl said. “You can hit a muscle group unintentionally. You might be trying to get a depressor with your Botox, and it spreads, and you actually have the face sag or sink, or you have the eyebrow look like it’s springing up.”
That’s why it’s important to see providers experienced with the procedure (ask how often they have use the therapy). And seeing a specialist in the area being treated – whether it’s a movement disorders expert, an eye doctor or a dentist – is a top piece of advice, both doctors said. “We should be experts in the anatomy of this space,” Diehl said. “We work in it every day.”