Tratamento integrado para correção do sorriso gengival: relato de caso / Integrated treatment for correction of gingival smile: case report

O sorriso gengival possui inúmeras causas, podendo acontecer por motivos esqueléticos, musculares ou por alteração no desenvolvimento dos tecidos de suporte. No entanto, na atualidade, a estética vermelha e a branca têm se apresentado completamente passíveis de transformações e com uma gama de procedimentos cirúrgicos ou não cirúrgicos para sanar as queixas dos pacientes. O objetivo geral deste trabalho é mostrar o poder que a odontologia tem frente às questões estéticas, como, por exemplo, a vergonha de sorrir por não se sentir confortável com os dentes curtos e com uma grande faixa de gengiva sendo exposta. O método utilizado foi um relato de caso. Que descreve todos os passos clínicos do tratamento de um paciente de 40 anos, que estava insatisfeita com o seu sorriso por apresentar erupção passiva alterada juntamente com hiperatividade do lábio superior. O plano de tratamento escolhido foi de realizar a cirurgia de aumento de coroa clínica estético, seguido de clareamento dentário e posteriormente um reposicionamento labial, com ajuda da toxina botulínica. Finalizando, para ajudar na cicatrização, o uso de laserterapia. O resultado de todo o processo cirúrgico envolvido neste trabalho, é satisfação do paciente, materializando o sonho deste, devolvendo segurança e espontaneidade ao sorrir. Pôde-se observar que através da combinação de técnicas cirúrgicas periodontais para tratar o sorriso gengival, obtém-se êxito tanto no sentido científico quanto no biológico, alcançando um sorriso esteticamente mais atrativo(AU)

Gummy smile has numerous causes, which can occur for skeletal or muscular reasons or due to changes in the development of supporting tissues. However, nowadays, the red and white aesthetics have been completely capable of transformation and with a range of surgical or non-surgical procedures to resolve patients' complaints. The general objective of this work is to show the power that dentistry has in the face of aesthetic issues, such as, for example, the shame of smiling due to not feeling comfortable with short teeth and a large strip of gum being exposed. The method used was a case report. Which describes all the clinical steps of the treatment of a 40-year-old patient, who was dissatisfied with her smile due to an altered passive eruption together with hyperactivity of the upper lip. The chosen treatment plan was to perform aesthetic clinical crown augmentation surgery, followed by tooth whitening and later lip repositioning, with the help of botulinum toxin. Finally, to help with healing, the use of laser therapy. The result of the entire surgical process involved in this work is patient satisfaction, materializing the patient's dream, restoring security and spontaneity when smiling. It was observed that through the combination of periodontal surgical techniques to treat gummy smile, success is achieved both in the scientific and biological sense, achieving a more aesthetically attractive smile(AU)

Medication refractory restless legs syndrome: Real-world experience.

BACKGROUND: Restless Legs Syndrome (RLS), impacting 5-13% of the population, poses challenges in long-term management. A knowledge gap exists in predicting resistance to first-line therapies. OBJECTIVE: To identify demographic and clinical factors predictive of refractory cases. METHODS: This retrospective study, conducted at the Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine, Houston, Texas (January 2018 to September 2023) identified all patients with RLS evaluated during the pre-specified period and compared clinical and demographic data between medication-refractory ("malignant") group and "benign" cohort. RESULTS: Among 132 patients with RLS, 23 (17.4%) were categorized as medication-refractory. This cohort was characterized by a significantly lower mean age at onset (39.3 vs. 53.5 years, p = 0.0005), longer disease duration (26.7 vs. 14.0 years), and a higher prevalence of a positive family history of RLS among first-degree relatives compared to the "benign" group (56.5% vs. 15.5%, p = 0.003). Furthermore, compared to the "benign" group, in the refractory group dopamine agonists were initiated as the primary medication at a significantly higher rate (p = 0.006). CONCLUSION: Our study found that a younger age at disease onset, prolonged disease duration, initial use of dopamine agonists, and a positive family history increased the likelihood of refractory RLS. We caution against the use of dopamine agonists, especially in young patients with RLS. Additionally, botulinum toxin might be considered a viable second-line treatment, especially for patients with otherwise medically-refractory RLS.

Clinical benefit of botulinum toxin for treatment of persistent TMD-related myofascial pain: A randomized, placebo-controlled, cross-over trial.

BACKGROUND: Injections of botulinum toxin type A (BoNT-A) have been proposed as an additional treatment modality for patients suffering chronic temporomandibular disorder (TMD)-related myofascial pain (MFP). BoNT-A impairs muscle function, along with its analgesic effect, and a minimal effective dose should be used. The objective of this randomized placebo-controlled crossover study was to evaluate the clinical benefit of a moderate dose (50 U) of BoNT-A. METHODS: Sixty-six subjects were randomized into two groups, one which received BoNT-A first and a second which received a saline solution (SS) first. Follow-ups were performed 2, 11, and 16 weeks after the injections. Diagnostic criteria for temporomandibular disorders (DC/TMD) diagnostic algorithms were used to evaluate characteristic pain intensity (CPI) and pain-related disability based on the Graded Chronic Pain Scale (GCPS). Electromyographic and bite force were also evaluated. RESULTS: The within-group analysis showed a significant improvement in pain intensity and pain-related disability after BoNT-A (p < 0.001, p = 0.005, p = 0.011) and SS (p = 0.003, p = 0.005, p = 0.046) injections up to week 16. The between-group analysis of pain-related variables revealed no differences between groups at any time. Nonetheless, BoNT-A, but not SS, caused a significant decline in muscle performance. The number needed to treat (NNT) regarding a clinically significant pain reduction (≥30%) was 6.3, 57.0, and 19.0 at 2, 11, and 16-week follow-ups favoring BoNT-A. CONCLUSIONS: Injections of 50 U of BoNT-A might improve MFP symptoms, but the specific effect of the drug on pain compared to the placebo is not obvious.

Effects of the combination of various pharmacological treatments and exercise on knee osteoarthritis: a systematic review and network meta-analysis.

Purpose: The combination of pharmacological and non-pharmacological interventions is strongly recommended by current guidelines for knee osteoarthritis. However, few systematic reviews have validated their combined efficacy. In this study, we investigated the effects of the combination of pharmacological agents and exercise on knee osteoarthritis. Methods: Randomized controlled trials that investigated the efficacy of pharmacological agents combined with exercise for knee osteoarthritis were searched in PubMed, Embase, and Cochrane Library up to February 2024. The network meta-analysis was performed within the frequentist framework. Standardized mean difference (SMD) with 95% CI was estimated for pain and function. Grading of recommendations, assessment, development, and evaluations were used to evaluate the certainty of evidence. Results: In total, 71 studies were included. The combination therapy outperformed pharmacological or exercise therapy alone. Among the various pharmacological agents combined with exercise, mesenchymal stem cell injection was ranked the best for short-term pain reduction (SMD: -1.53, 95% CI: -1.92 to -1.13, high certainty), followed by botulinum toxin A, dextrose, and platelet-rich plasma. For long-term pain relief, dextrose prolotherapy was the optimal (SMD: -1.76, 95% CI: -2.65 to -0.88, moderate certainty), followed by mesenchymal stem cells, platelet rich in growth factor, and platelet-rich plasma. Conclusion: Exercise programs should be incorporated into clinical practice and trial design. For patients undergoing exercise therapies, mesenchymal stem cell, dextrose, platelet-rich plasma, platelet rich in growth factor, and botulinum toxin A may be the optimal agents.

Assessment of the Efficacy and Durability of IncobotulinumtoxinA in the Treatment of the Upper Face in Adult Women.

INTRODUCTION: IncobotulinumtoxinA (Xeomin®) is used in the treatment of dynamic wrinkles and the aesthetic repositioning of facial structures. The duration of its muscular effect typically extends for around 4 months. However, the residual aesthetic benefit can be observed for a longer period. To date, the long-term aesthetic benefit of incobotulinumtoxinA in facial aesthetics has not been systematically evaluated. This study aimed to evaluate longitudinally the duration and aesthetic benefits of incobotulinumtoxinA in the treatment of the upper face in adult women. METHODS: A quasi-experimental, evaluator-blind, clinical trial involving 28 adult women (30-60 years old) with facial movement lines, undergoing treatment of the upper face with incobotulinumtoxinA by two injectors, following an individualized protocol (ONE21 and glabellar contraction patterns) was performed. Participants were evaluated on the day of the intervention (day 0) and days 30, 120, 180, and 240, and subjected to standardized photographs. The following outcomes were evaluated blindly at each visit: Merz Aesthetics Facial Contraction Scale (MAS), GAIS (Global Aesthetic Improvement Scale), and patient satisfaction. Adverse effects were evaluated at each visit. RESULTS: Participants ranged in age from 30 to 60 years, 93% were self-declared white, and most of their baseline MAS scores for dynamic lines were moderate and severe. All the parameters presented significative reduction from baseline until day 180. At day 240, the dynamic MAS scores were lower than baseline for forehead lines in 15.4% (95% confidence interval (CI) 0.8-30.0%) of the participants, for glabellar lines in 38.5% (95% CI 18.8-58.1%), and for crow's feet lines in 26.9% (95% CI 9.0-44.8%). Aesthetic improvement compared to baseline was identified in 35% (CI 95% 23‒50%) of the participants at day 240, and 62% (CI 95% 42‒81%) of the sample kept reporting some satisfaction with the procedure. CONCLUSION: The aesthetic treatment of the upper face with incobotulinumtoxinA demonstrates enduring clinical benefits, and patient satisfaction lasting up to 180 days in most participants. The length of efficacy, which exceeded those reported in the literature, may be attributed to the use of techniques based on individualized assessment such as ONE21 and glabellar patterns of contraction.

Gait analysis using three-dimensional motion and ground reaction force systems in patients with hemiplegia treated with botulinum toxin type A in ankle plantar flexors.

Objective: The efficacy of botulinum toxin type A (BoNT-A) injection on spasticity has usually been measured using the range of motion (ROM) of joints and Modified Ashworth Scale (MAS); however, they only evaluate muscle tone at rest. We objectively analyzed the gait of three patients with hemiplegia using three-dimensional motion analysis and ground reaction force (GRF) systems to evaluate muscle tone during gait. Materials and Methods: We measured passive ankle dorsiflexion ROM with knee extension and the MAS score for clinical evaluation, and gait speed, stride length, single-leg support phase during the gait cycle, joint angle, joint moment, and GRFs for kinematic evaluation before and one month after BoNT-A injection. Results: All patients showed an increase in ankle dorsiflexion ROM, improvement in MAS score, and increase in stride length. Case 1 showed an increase in gait speed, prolongation of the single-leg support phase, increase in hip extension angle and moment, and improvement in the vertical and anterior-posterior components of the GRFs. Case 2 showed an increase in gait speed, improvement in double knee action, increase in ankle plantar flexion moment, and improvement in propulsion in the progressive component of the GRFs. Case 3 exhibited a laterally directed force in the GRFs. Conclusion: We evaluated the effects of BoNT-A injections in three patients with hemiplegia using three-dimensional motion analysis and GRFs. The results of the gait analysis clarified the improvements and problems in hemiplegic gait and enabled objective explanations for patients.

Effectiveness of Botulinum Toxin Injection With Casting in Children With Spastic Cerebral Palsy: A Randomized Controlled Trial.

BACKGROUND: The most common form of movement disorder presented in children with cerebral palsy is spasticity, and dynamic equinus is the most common spastic ankle deformity. Botulinum toxin (BT) injection is now an established first-line treatment for focal spasticity. AIM: To assess the effects of BT injection with casting in the treatment of dynamic equinus in children diagnosed with cerebral palsy with spastic diplegia. SETTING AND DESIGN: A prospective randomized controlled trial was conducted among patients aged 2-12 years with cerebral palsy and spastic diplegia, attending the general outpatient department and admitted to the indoor facility of the Department of Physical Medicine and Rehabilitation and the Department of Pediatric Orthopedics at King George's Medical University, Lucknow. MATERIAL AND METHODS: Two groups of 19 patients each were formed. Group A received BT injection with casting, whereas in group B, only a cast was applied. Outcome measures including spasticity by Modified Ashworth Scale (MAS), Modified Tardieu Scale (MTS), range of motion (ROM), passive ankle dorsiflexion, and Gross Motor Function Measure (GMFM-66) (dimensions D and E) were assessed before and after the intervention. RESULTS: The participants in groups A and B were age-matched. A statistically significant difference was seen within group A and group B for MAS, passive ROM-dorsiflexion (PROM-DF), and passive ROM-plantarflexion (PROM-PF) at various follow-ups. In the 3rd week, MAS in each group was statistically insignificant (p-value> 0.05). CONCLUSION: There was a significant improvement in tone and a significant increase in the passive range of motion in both groups.

A novel approach to treating post-stroke depression: administration of Botulinum Toxin A via local facial injection.

Background: Post-stroke depression (PSD) is a frequent complication following a stroke, characterized by prolonged feelings of sadness and loss of interest, which can significantly impede stroke rehabilitation, increase disability, and raise mortality rates. Traditional antidepressants often have significant side effects and poor patient adherence, necessitating the exploration of more suitable treatments for PSD. Previous researchers and our research team have discovered that Botulinum Toxin A (BoNT-A) exhibits antidepressant effects. Therefore, our objective was to assess the efficacy and side effects of BoNT-A treatment in patients with PSD. Methods: A total of 71 stroke patients meeting the inclusion criteria were allocated to the two group. 2 cases were excluded due to severe neurological dysfunction that prevented cooperation and 4 cases were lost follow-up. Ultimately, number of participants in the BoNT-A group (n = 32) and Sertraline group (n = 33). Treatment efficacy was evaluated 1, 2, 4, 8 and 12 weeks post-treatment. Results: There were no significant differences in baseline characteristics between the two groups (p > 0.05). Both groups exhibited comparable treatment efficacy, with fewer side effects observed in the BoNT-A group compared to the Sertraline group. BoNT-A therapy demonstrated significant effects as early as the first week (p < 0.05), and by the 12th week, there was a notable decrease in neuropsychological scores, significantly lower than the baseline level. The analysis revealed significant differences in measurements of the Hamilton Depression Scale (HAMD) (F(770) = 12.547, p = 0.000), Hamilton Anxiety Scale (HAMA) (F(951) = 10.422, p = 0.000), Self-Rating Depression Scale (SDS) (F(1385) = 10.607, p = 0.000), and Self-Rating Anxiety Scale (SAS) (F(1482) = 11.491, p = 0.000). Conclusion: BoNT-A treatment effectively reduces depression symptoms in patients with PSD on a continuous basis.

Study on botulinum toxin in dermatology from 2000 to 2023: A CiteSpace-based bibliometric analyses.

OBJECTIVE: Using bibliometric methods, this study analyzed and summarized the current situation and development of the global application of botulinum toxin in dermatology. METHODS: Literature published in the Web of Science Core Collection database from January 1, 2000 to October 28, 2023 was searched for topics such as "Botulinum toxin," "Dermatology," and so forth. The number of publications, countries, institutions, journals, authors, cited literature, keywords, and so forth, were analyzed and a visual knowledge map was created using scientometric tools such as CiteSpace, VOSviewer, and Scimago Graphica. RESULTS: A total of 2039 documents were retrieved and 1877 documents were included after de-duplication and transformation. The country with the highest number of published periodical articles was the United States; the main research institution was Yonsei University; the author with the highest number of published periodical articles was Kim, Hee Jin; and the high-frequency keywords mainly related to indications, combination therapy, and safety optimization. CONCLUSION: The results of this study provide information on the current status and trends in clinical studies of botulinum toxin in dermatology, which will help researchers identify hotspots and explore new research directions in this field.

Surgical management of chronic sixth cranial nerve palsy: case report and literature review.

Background: Esotropia resulting from sixth cranial nerve palsy can substantially impact an individual's visual acuity and overall quality of life. If the condition does not resolve in 6-10 months, surgical intervention may be necessary. Various muscle surgeries may be considered, with vertical rectus muscle transposition emerging as the primary option for treatment of complete palsy. However, this technique carries the risk of anterior segment ischemia and post-surgery deviations. Herein, we present a successful treatment of chronic complete sixth nerve palsy using a modified Nishida procedure, without splitting or tenotomy, and an adjunct botulinum toxin A (BTA) injection in the ipsilateral medial rectus muscle. Case Presentation: A 59-year-old woman with a history of traumatic sixth nerve palsy had previously undergone horizontal muscle strabismus surgeries. Following multiple left medial rectus recessions, lateral rectus resection, and BTA injections, esotropia persisted. The worsening of her condition led to emotional distress and impaired social interaction. Initial examination revealed marked esotropia and limited left eye abduction. Magnetic resonance imaging (SIGNA MR750w, GE Healthcare, Waukesha, WI, USA) of the left eye revealed a contracted medial rectus muscle and substantial atrophy of the left lateral rectus muscle. A modified Nishida procedure was performed with an injection of 3 units of BTA into the ipsilateral medial rectus muscle, resulting in improved ocular alignment and stable findings after nine postoperative months. Furthermore, we supported our successful outcome with a summary of similar reported cases of sixth nerve palsy managed using the modified Nishida procedure with or without adjunctive procedures. Conclusions: Following the modified Nishida procedure, the patient experienced a reduction in diplopia, improved ocular alignment and stability, and an increased binocular diplopia-free field. This case underscores the importance of an individualized approach to complex strabismus cases and highlights the modified Nishida procedure as a valuable tool in such circumstances. In the future, strabismus management will focus on refining personalized treatment and exploring innovative techniques for complex cases. Our success in using a combination of Nishida procedure and BTA injection should be further investigated in large-scale studies.

Efficacy and safety of onabotulinumtoxinA for the treatment of overactive bladder in men and women: A pooled analysis.

BACKGROUND: This pooled analysis of randomized controlled studies investigated the safety and efficacy of onabotulinumtoxinA in male and female patients with overactive bladder (OAB). METHODS: Data were pooled from four similarly designed trials in North America and Europe. Adults with idiopathic OAB for ≥6 months inadequately managed by at least one anticholinergic were randomized 1:1 or 2:1 to receive onabotulinumtoxinA 100 U or matched placebo in Cycle 1 and could request open-label retreatment with onabotulinumtoxinA 100 U at ≥12 weeks. Efficacy outcomes at Week 12 included the primary endpoint of mean urinary incontinence (UI) episodes per day and other variables, such as the proportion of patients with ≥50% reduction in daily UI episodes. Safety was assessed by monitoring treatment-emergent adverse events (TEAEs). Analyses by sex were descriptive. Males were further analyzed by benign prostatic hyperplasia (BPH) diagnosis status. RESULTS: In the pooled population (N = 1564), there were 194 males (12.4%) and 1370 females (87.6%). Mean number of baseline UI episodes per day was 4.9 in males and 5.5 in females. At Week 12, numerically greater mean reductions from baseline in number of daily UI episodes were observed with the onabotulinumtoxinA 100 U group (females: -3.0; males: -2.2) versus placebo (females: -1.1; males: -1.3). Achievement of ≥50% reduction in daily UI episodes was numerically greater with onabotulinumtoxinA 100 U (females: 64.8%; males: 61.2%) versus placebo (females: 30.6%; males: 44.8%), and numerically higher in males without BPH (onabotulinumtoxinA: 65.1%; placebo: 50.9%) versus with BPH (onabotulinumtoxinA: 54.3%; placebo: 36.6%). A total of 34.7% of males and 39.4% of females experienced at least one TEAE in the first 12 weeks during treatment Cycle 1. Urinary tract infection rate was 13.1% in females and 4.2% in males; incidence of hematuria was 6.8% in males and 1.1% in females. Incidence of urinary retention (defined as incomplete emptying, requiring catheterization) was 2.7% in females and 4.7% in males. CONCLUSION: OnabotulinumtoxinA 100 U was efficacious and well tolerated in men and women with OAB, including in males with and without BPH. No new safety findings were identified when data were analyzed by sex.

Comparison of the effect of intra-dermal injection of botulinum toxin and normal saline in the treatment of facial skin pores.

Background and Purpose: Skin pores (SPs) are normal and benign skin structures that are mostly located on the face (nose, cheeks, etc.) that cause many aesthetic concerns or complaints. One known effective treatment is botulinum toxin A (BTXA), which is also approved for the treatment of strabismus, blepharospasm, muscle spasm, cervical dystonia, glabella wrinkles, and primary axillary hyperhidrosis. Therefore, the aim of this study was to compare the effect of intra-dermal injection of botulinum toxin and normal saline serum (NSS) in the treatment of large facial pores. Methods: The study included 25 people who referred to the skin clinic of Imam Khomeini Hospital in Ahvaz from June 2021 to January 2022 for the treatment of large facial skin pores. Randomly, some subjects were injected with botulinum toxin at ten points, and each point was equivalent to 2.5 units of Masport (500 units vial of Masport diluted with 10 ml of NSS). Some other people were injected with 0.05 ml of NSS by intra-dermal injection at ten points. Finally, the data were analyzed using SPSS-Ver. 22 software. Results: Based on optical coherence tomography results, it was determined that the diameter of facial pores decreased significantly (P = 0.011). Dermoscopy showed a significant decrease in the average size of facial pores (P < 0.011), and also, the pore score decreased significantly (P = 0.021). In addition, the results showed that the size of skin pores and facial fat on both sides of the face did not decrease significantly from the patients' point of view (P = 0.71). Conclusion: Based on the results of the present study, it can be concluded that intra-dermal injection of botulinum toxin is an effective and safe method to control facial pores, which showed acceptable results after 3 months.

Repeated unilateral injections of botulinum toxin in masticatory muscles in adult rats do not amplify condylar and alveolar bone loss nor modify the volume of the hypertrophic bone proliferation at enthesis.

OBJECTIVES: Botulinum toxin is used in human in repeatedly masticatory muscles injections. A single BTX injection in animal induces mandibular bone loss with a muscle enthesis hypertrophic metaplasia. Our aim was to evaluate mandibular bone changes after unilateral repeated injections of BTX in adult rats. STUDY DESIGN: Mature male rats were randomized into 3 groups: one, two or three injections. Each rat received injections in right masseter and temporalis muscles. The left side was the control side. Microcomputed tomography was used to perform 2D and 3D analyses. RESULTS: Bone loss was evidenced on the right sides of alveolar and condylar bone. Alveolar bone volume increased in both control left side and injected right side whereas condylar bone volume remained constant in all groups, for both sides. Enthesis bone hypertrophic metaplasias were evidenced on the BTX injected sides without any modification with the number of injections. CONCLUSION: BTX repeated injections in masticatory muscles lead to major mandibular condylar and alveolar bone loss that does not worsen. They lead to the occurrence of an enthesis bone proliferation that is not dependent on the number of injections. These results are an argument for the safety of BTX injections in masticatory muscles in human.

Comparative study between the efficacy of prabotulinum toxin-A versus onabotulinum toxin-A for the treatment of upper facial expression lines.

BACKGROUND: Botulinum Toxin (BoNTA) is the most used nonsurgical aesthetic procedure to treat facial expression lines. AIMS: This study compared the efficacy of Prabotulinum toxin-A, a novel BoNTA that originates from Clostridium botulinum Hall-A, with onabotulinum toxin-A in treating facial expression lines using the Facial Wrinkle Scale (FWS) and FACE-Q questionnaires. METHODS: This was an experimental, comparative, longitudinal, open-label, and prospective study. Patients aged between 25 and 40 years with upper-third facial expression lines were included. Follow-ups were made at three, seven, 30, and 120 days. RESULTS: A total of 26 patients were included: 20 female, and six males, with a mean age of 28.26 years. An average of 31.00 IU and 31.38 IU were administered to the onabotulinum and prabotulinum groups, respectively. The prabotulinum group demonstrated superiority in FWS and Face-Q scores between the first and third days (p ≤ 0.001, p < 0.001, respectively), which continued on day 7. By day 30, there were no differences in the scores of the two questionnaires. CONCLUSIONS: Prabotulinum toxin-A is a safe and effective treatment for upper-third facial wrinkles. On day three and seven, the results suggest that prabotulinum toxin-A has a quicker onset of action than onabotulinum toxin-A. On days 30 and 120, both groups showed similar FWS and Face-Q scores.

Effects of botulinum toxin type A in patients with painful temporomandibular joint disorders: a systematic review and meta-analysis.

Objective: To assess the therapeutic efficacy of botulinum toxin type A (BTX-A) for managing myofascial pain related to temporomandibular disorders (TMDs). Methods: This study was conducted according to the PRISMA 2020 statement guidelines. The PubMed, Embase, and Cochrane Library databases were searched. Only randomized controlled trials were included. The primary outcome was a pain score on the visual analog scale, and the secondary outcomes were maximum mouth opening and adverse effects. The Cochrane risk of bias tool was used to assess risk bias. A meta-analysis of studies with the same interventions, controls, assessment methods, and follow-up durations was performed. Results: A total of 519 studies were retrieved, of which 20 randomized controlled trials were included in the qualitative analysis and six were included in the meta-analysis. The results showed that, compared with placebo, BTX-A injection was more effective at relieving myofascial pain, and its effect was similar to that of conventional methods. However, there was no difference in maximum mouth opening between the two groups. After the study assessment with the RoB 2.0 tool, six studies showed a low risk of bias, 13 studies showed some concerns regarding the reported results, and only one study showed a high risk of bias. Adverse effects of BTX-A injection were observed in four studies. Conclusions: In conclusion, BTX-A is effective at relieving pain in TMD patients but does not improve mouth opening. To minimize adverse effects, we recommend a low dose of BTX-A for TMD patients who do not experience complete pain relief from conservative treatments.

Long-term efficacy of fractional microneedle radiofrequency versus botulinum toxin-A in primary axillary hyperhidrosis: a randomized controlled trial.

Primary axillary hyperhidrosis is an idiopathic disorder that creates severe psycho-social burden due to excessive uncontrolled sweating. Various therapeutic agents have been described, but each has its own limitations. The use of fractional microneedling radiofrequency has emerged lately with promising results. This study aimed to determine the efficacy and safety of fractional microneedle radiofrequency in comparison to Botulinum toxin-A (BT-A) in patients with primary axillary hyperhidrosis. In this randomized controlled clinical trial, 20 patients (40 sides) were randomized to either fractional microneedle radiofrequency (4 sessions at 3-week intervals) or BT-A (single session), where each side received one of the treatment modalities. Efficacy was measured at 3, 6 and 12 months using Minor's starch iodine test, HDSS score, Hqol questionnaire, and patient satisfaction. Fractional microneedle radiofrequency, although showed moderate efficacy, is inferior to BT-A regarding longitudinal efficacy at 12 months, as well as patients' satisfaction. Both treatment modalities showed to be equally safe, but fractional microneedle radiofrequency procedure was substantially more painful. In conclusion, fractional microneedle radiofrequency does not offer a better substitute to BT-A in primary axillary hyperhidrosis. BT-A shows higher efficacy, is less painful, less expensive, and needs a smaller number of sessions.

Sustained benefits of onabotulinumtoxinA treatment in chronic migraine: An analysis of the pooled Phase 3 REsearch Evaluating Migraine Prophylaxis Therapy (PREEMPT) randomized controlled trials.

OBJECTIVE: To characterize the long-term (56-week) benefits of continuous onabotulinumtoxinA treatment response in individuals with chronic migraine (CM) who achieved reduction to <15 headache days/month with treatment. BACKGROUND: There are limited data exploring reductions in monthly headache days to levels consistent with episodic migraine among those experiencing CM. Understanding the impact of sustained preventive treatment response in CM can provide important information about the impact of successful therapy. METHODS: The two Phase 3 REsearch Evaluating Migraine Prophylaxis Therapy trials of onabotulinumtoxinA in adults included a 24-week, randomized, double-blind, placebo-controlled phase and a 32-week open-label phase. Data were pooled to determine proportions of individuals with <15 headache days/month while on treatment during several time periods in the double-blind phase (Weeks 21-24; any 12 consecutive weeks; Weeks 13-24) and the entire study (Weeks 53-56; any 12 consecutive weeks; any 4-week period). We assessed the long-term impact on mean monthly headache days and changes from baseline on the six-item Headache Impact Test (HIT-6) and Migraine-Specific Quality of Life questionnaire version 2.1 (MSQv2.1). RESULTS: We analyzed 1384 participants with chronic migraine (double-blind: onabotulinumtoxinA, n = 688; placebo, n = 696; open-label: n = 688 [onabotulinumtoxinA]). The discontinuation rates prior to the completion of the full 56-week treatment period for onabotulinumtoxinA and placebo were 25.4% (n = 175) and 29.3% (n = 204), respectively. During Weeks 13-24 of the double-blind phase, significantly more onabotulinumtoxinA-treated (386/688 [56.1%]) than placebo-treated (342/696 [49.1%]) individuals had <15 headache days/month (p = 0.010), with fewer monthly headache days for onabotulinumtoxinA versus placebo responders. The proportions of participants achieving <15 monthly headache days with onabotulinumtoxinA were 60.9% (419/688) at Weeks 25-56, 81.1% (558/688) at Weeks 53-56, and 79.4% (546/688) during any consecutive 12-week period. Mean changes from baseline on the HIT-6 and MSQv2.1 questionnaire surpassed within-group minimal important difference thresholds in all periods. At Week 24, onabotulinumtoxinA-treated participants who achieved <15 monthly headache days during Weeks 21-24 had a greater mean HIT-6 score reduction (-6.5 vs. -1.4) and greater mean MSQv2.1 Role-Function Restrictive score improvements (21.3 vs. 6.4) than those who did not achieve <15 monthly headache days during the same period. CONCLUSIONS: Participants who achieved <15 monthly headache days with onabotulinumtoxinA treatment achieved meaningful benefits in headache-related disability and migraine-specific quality of life compared with those who remained at or above the 15-monthly headache days threshold. Sustained benefits observed over 56 weeks support long-term onabotulinumtoxinA use for the prevention of CM.

Mobile digital gait analysis captures effects of botulinum toxin in hereditary spastic paraplegia.

BACKGROUND AND PURPOSE: Hereditary spastic paraplegias (HSPs) comprise a group of inherited neurodegenerative disorders characterized by progressive spasticity and weakness. Botulinum toxin has been approved for lower limb spasticity following stroke and cerebral palsy, but its effects in HSPs remain underexplored. We aimed to characterize the effects of botulinum toxin on clinical, gait, and patient-reported outcomes in HSP patients and explore the potential of mobile digital gait analysis to monitor treatment effects and predict treatment response. METHODS: We conducted a prospective, observational, multicenter study involving ambulatory HSP patients treated with botulinum toxin tailored to individual goals. Comparing data at baseline, after 1 month, and after 3 months, treatment response was assessed using clinical parameters, goal attainment scaling, and mobile digital gait analysis. Machine learning algorithms were used for predicting individual goal attainment based on baseline parameters. RESULTS: A total of 56 patients were enrolled. Despite the heterogeneity of treatment goals and targeted muscles, botulinum toxin led to a significant improvement in specific clinical parameters and an improvement in specific gait characteristics, peaking at the 1-month and declining by the 3-month follow-up. Significant correlations were identified between gait parameters and clinical scores. With a mean balanced accuracy of 66%, machine learning algorithms identified important denominators to predict treatment response. CONCLUSIONS: Our study provides evidence supporting the beneficial effects of botulinum toxin in HSP when applied according to individual treatment goals. The use of mobile digital gait analysis and machine learning represents a novel approach for monitoring treatment effects and predicting treatment response.

Effect of ultrasound-guided injection of botulinum toxin type A into shoulder joint cavity on shoulder pain in poststroke patients: study protocol for a randomized controlled trial.

BACKGROUND: Hemiplegic shoulder pain (HSP) is a common complication after stroke. It severely affects the recovery of upper limb motor function. Early shoulder pain in hemiplegic patients is mainly neuropathic caused by central nerve injury or neuroplasticity. Commonly used corticosteroid injections in the shoulder joint can reduce shoulder pain; however, the side effects also include soft tissue degeneration or increased tendon fragility, and the long-term effects remain controversial. Botulinum toxin injections are relatively new and are thought to block the transmission of pain receptors in the shoulder joint cavity and inhibit the production of neuropathogenic substances to reduce neurogenic inflammation. Some studies suggest that the shoulder pain of hemiplegia after stroke is caused by changes in the central system related to shoulder joint pain, and persistent pain may induce the reorganization of the cortical sensory center or motor center. However, there is no conclusive evidence as to whether or not the amelioration of pain by botulinum toxin affects brain function. In previous studies of botulinum toxin versus glucocorticoids (triamcinolone acetonide injection) in the treatment of shoulder pain, there is a lack of observation of differences in changes in brain function. As the content of previous assessments of pain improvement was predominantly subjective, objective quantitative assessment indicators were lacking. Functional near-infrared imaging (fNIRS) can remedy this problem. METHODS: This study protocol is designed for a double-blind, randomized controlled clinical trial of patients with post-stroke HSP without biceps longus tenosynovitis or acromion bursitis. Seventy-eight patients will be randomly assigned to either the botulinum toxin type A or glucocorticoid group. At baseline, patients in each group will receive shoulder cavity injections of either botulinum toxin or glucocorticoids and will be followed for 1 and 4 weeks. The primary outcome is change in shoulder pain on the visual analog scale (VAS). The secondary outcome is the assessment of changes in oxyhemoglobin levels in the corresponding brain regions by fNIRS imaging, shoulder flexion, external rotation range of motion, upper extremity Fugl-Meyer, and modified Ashworth score. DISCUSSION: Ultrasound-guided botulinum toxin type A shoulder joint cavity injections may provide evidence of pain improvement in patients with HSP. The results of this trial are also help to analyze the correlation between changes in shoulder pain and changes in cerebral hemodynamics and shoulder joint motor function. TRIAL REGISTRATION: Chinese clinical Trial Registry, ChiCTR2300070132. Registered 03 April 2023, https://www.chictr.org.cn/showproj.html?proj=193722 .