Neuromodulator (Botox) FAQs

If you have any addition questions, feel free to ask Dr. Nicole Robins at your next visit!

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What are neuromodulators and how do they work?

The term neuromodulator is an umbrella term that encompasses various brands of botulinum toxin type A products.

Botox is the most widely recognized brand name, but some other neuromodulators are Dysport and Xeomin
While they all work in a similar way, each brand has unique formulation differences that may influence diffusion, onset time, and duration of effect.
Neuromodulators are agents that alter nerve activity by inhibiting signal transmission.
They block nerve signals to muscles temporarily relax overactive muscles

What types of neuromodulators are commonly used and why?

Commonly used neuromodulators include Botox, Dysport, and Xeomin. Each has unique properties:

Botox: Widely recognized and FDA-approved for various facial areas, known for its consistent results.
Dysport: Spreads effectively, making it suitable for larger areas like the forehead, and often has a quicker onset.
Xeomin: Lacks accessory proteins, potentially reducing the risk of antibody development.

The choice among these depends on individual patient needs and what Dr. Nicole thinks is best.

What is the difference between the different brands of neuromodulators?

All neuromodulators are derived from botulinum toxin type A and function similarly by relaxing targeted muscles. How they differ is in formulation, onset of action, diffusion characteristics, and duration of effect.

Why are dentists considered some of the best professionals for administering Botox? What training are dentists required to do for injectables?

Dentists undergo extensive training before they are licensed to administer Botox, ensuring a high standard of safety and competency. Compared to some other professionals who may be legally allowed to perform injections after a short course, dental regulatory bodies require a more in-depth educational process.

In Canada, the dental professional college responsible for licensing strictly regulates Botox training, only recognizing two university-based programs as acceptable for obtaining a license:

At the U of A, the Neuromodulators and Fillers program is structured into multiple levels to ensure dentists have a strong foundation in facial anatomy and injection techniques:

Level 1: Covers applied anatomy and an introduction to neuromodulators. It includes didactic lectures and an anatomical cadaver lab to develop a comprehensive understanding of the head and neck anatomy relevant to neuromodulator use. Completion of this foundational course is required before advancing.
Level 2: Focuses on basic neuromodulator applications, including treatments for the upper face and bruxism. This level includes lectures, cadaver lab sessions, and hands-on injection practice to build clinical confidence.
Level 3: Explores advanced applications, including neuromodulator use for the mid-to-lower face, neck, and myofascial pain treatment. This level involves in-depth lectures and hands-on practice to ensure proficiency.

This structured training process ensures that dentists meet strict regulatory standards before offering Botox treatments, reinforcing patient safety and the highest level of care.

At institutions like the University of Alberta, dentists can enroll in specialized continuing education programs focused on neuromodulators and fillers. These programs often have multiple levels, each building upon the previous one. For instance, to enroll in advanced courses, dentists might need to complete prior levels, wait a specified period (e.g., one year), and submit a portfolio of cases demonstrating their experience.

What are the therapeutic ways to use Botox?

Beyond cosmetic applications, Botox has several therapeutic uses:

Chronic migraines (Forehead, Temples, Neck, & Shoulders): Approved for reducing the frequency of chronic migraine headaches by blocking pain signals and relaxing muscles that contribute to tension headaches.
Jaw (Masseter Muscles) – Helps with bruxism (teeth grinding), TMJ disorders, and jaw tension, reducing pain and preventing tooth damage.
Muscle Spasms (Various Areas): Treats spasms caused by conditions like cerebral palsy or dystonia.
Hyperhidrosis (Underarms, Palms, Feet, & Scalp): Reduces excessive sweating
Esophagus (for Dysphagia or Achalasia): Relaxes the muscles for swallowing disorders.
Overactive bladder (Bladder Wall): Helps with urinary incontinence.

These applications take advantage of Botox’s ability to temporarily relax overactive muscles or glands. Dr. Nicole specializes in the use of Botox for both cosmetic and therapeutic purposes, including the treatment of TMD, myofascial pain, bruxism (teeth grinding), headaches, and migraines.

How Botox Enhances the Effectiveness of Massage Therapy

Botox and massage therapy are complementary treatments that, when used together, can significantly enhance therapeutic outcomes.

While Botox works internally by relaxing overactive muscles and blocking excessive nerve signals, massage therapy works externally to improve circulation, release tension, and support muscle recovery.

When combined, these treatments can provide greater pain relief, improved mobility, and longer-lasting muscle relaxation for conditions such as TMJ dysfunction, chronic muscle tightness, migraines, and muscle spasms.

Can I get a prescription for therapeutic Botox?

If patients are interested in therapeutic Botox, they can book in for a consultation with Dr. Nicole to discuss if they are a good candidate for a Botox prescription. If Dr. Nicole determines a prescription is viable, the injections will be administered. A letter will then be provided to potentially cover future treatments. The letter can be given to the patient's doctor who can write a prescription that may be covered under health insurance. Patients will still be required to pay an injector fee.

If coverage is approved, patients will be required to bring the filled prescription to their next appointment with Dr. Nicole.

What can be expected during a Botox treatment?

Dr. Nicole will conduct a thorough consultation, discussing the patient’s health history, previous treatment experiences, and personal desires and expectations. Then she will carefully assess the patient’s anatomy and, with consent, provides a professional recommendation tailored to achieve the desired results safely and effectively, following best practice standards.

Dr. Nicole may recommend Botox®, Dysport®, or Xeomin® to address mild to moderate facial lines, wrinkles, muscle tension, TMJ dysfunction, bruxism, and various forms of orofacial pain, including headaches and migraines caused by muscle activity.

The injecting is a quick process that only takes a few minutes. A precise injection of a small amount of the selected neuromodulator is administered into targeted muscles to temporarily reduce their activity. This process leads to muscle relaxation, alleviation of tension-related discomfort, and an overall improvement in muscle function.

There is typically no downtime after the procedure, and patients can resume most of their normal activities immediately.

How many units of Botox do I need and where do I need it?

The required units of Botox vary depending on the treatment area, the severity of the condition, and individual factors such as muscle strength, size, and patient goals. For example, treating glabellar lines (frown lines between the eyebrows) may require 10-25 units, while forehead lines could need 10-30 units. Larger, stronger muscles generally require a large number of units. The total number of units will be determined by Dr. Nicole at the consultation when specific needs and desires are discussed.

Does the treatment cause pain?

Pain perception varies from patient to patient. Some areas of the face are more sensitive than others. When the injection is administered, a small pinch may be felt followed by a mild burning sensation. However, the discomfort is generally well tolerated and brief.

What does it feel like after treatment?

Following treatment, sensation to touch will remain the same, but contracting muscles and making certain facial expressions may feel more difficult. The forehead area may feel slightly heavy for a few days. Some patients report feeling "frozen" within a few days of treatment, but this sensation does not equate to a visibly frozen appearance. Mild, temporary headaches can occasionally occur after the initial treatment.

What are the post treatment instructions and details?

For 1 – 2 days post treatment:

DO NOT:
- Touch, press, rub or manipulate the injected areas for the rest of the day after treatment
- Apply any make up as it can lead to pustules
- Lie down or bend forward for at least 4 hours
- Use Retin–A treatment.
- Swim or undertake strenuous exercise
- Have exposure to extreme hot or cold temperatures or to large swings in temperatures (in the sun, sauna, etc.)
AVOID: Aspirin, Motrin, Ginko Biloba, Flax Oil, Cod Liver Oil. Vitamin A or Vitamin E or other essential fatty acids, alcohol, caffeine, niacin supplements, high sodium foods, high sugar foods, refined carbohydrates (you may eat fruit), spicy foods and cigarettes
One side may heal faster than the other.
Expect some bruising and swelling around the areas that were injected.
Apply ice for the first hour after treatment and for 10 min on and 10 min off.
Wait 2 weeks before any enhancements.

Report any immediately if it occurs.

How can I minimize the risk of bruising?

To reduce the likelihood of bruising, it is recommended that the following is avoided 24 hours before and after treatment:

Alcohol consumption, as it can thin the blood and increase bruising risk
Caffeine, niacin supplements, high-sodium foods, high-sugar foods, refined carbohydrates (fruit is acceptable), spicy foods, and cigarettes
Anti-inflammatory or blood-thinning medications should be avoided for 7 days prior to injecting
Vitamin E, Gingko Biloba, St. John’s Wort, Garlic, Flax Oil, Cod Liver Oil, Vitamin A, Ibuprofen, Aspirin, Motrin, Advil, Aleve, Vioxx, and other NSAIDs

Applying ice and gentle pressure after treatment can further reduce the risk of bruising.

How can I increase the lasting effects of Botox?

Some studies suggest that zinc supplementation prior to injection might prolong the effects of Botox. A 2012 study found that taking zinc could extend Botox's efficacy by about 30%. However, the evidence is limited, and results can vary. Factors like individual metabolism, lifestyle, and proper skin care also influence the longevity of Botox effects. Consulting with a healthcare provider before starting any supplementation is advisable.

Are there any potential side effects?

Common side effects include:

Mild discomfort, swelling or bruising at the injection site
Temporary mild headaches
A sensation of heaviness or tightness in treated muscles.
Patients undergoing masseter Botox treatment may notice slower, more deliberate chewing.

Uncommon side effects include:

Itching
Numbness
Twitching
Changes in facial expression, such as lowered eyebrows
Flu like symptoms
TMJ Dysfunction: Changes to the bite can cause temporary muscle splinting and facial pain. This will usually resolve after a month but can necessitate the need for splint therapy, bite adjustment or other therapy options.
Although rare, excessive masseter treatment can cause lower facial asymmetry, prominent cheekbones, or sunken cheeks.

When do the results take effect?

Botox does not provide immediate results. Some patients notice muscle weakening within the first few days, but visible results typically appear within 7 to 14 days after treatment.

Will others be able to tell that I have received Botox treatment?

After Botox takes effect, patients may experience a reduced ability to move the treated muscles; however, they will not appear frozen. Instead, they will have a more refreshed and well-rested appearance. Botox can also reduce pore size, limit excessive sweating, and improve skin texture. Patients receiving TMJ Botox treatment often experience relief from headaches and chewing-related discomfort. Additionally, masseter Botox treatment can create a more tapered and contoured lower face, while upper facial treatments, such as an eyebrow lift, can subtly enhance facial expressions.

How long do the results last?

The duration of Botox effects varies by individual but typically lasts between three and four months. Larger, stronger muscles generally require higher doses, and more frequent treatments. The effects of an initial Botox treatment may wear off sooner than subsequent treatments.

How often should I receive Botox treatment?

Refinement treatments should be scheduled no sooner than two weeks after the initial treatment.

Subsequent full treatments should be administered at least three months apart.

Botox typically begins to take effect within one week, reaches its peak effectiveness around two weeks, and lasts anywhere from two to six months.

An individualized recall schedule for optimal maintenance will be established by Dr. Nicole

Is continued treatment necessary once I start?

No, continued treatment is not required, though it may be recommended depending on the reason it is being used for. Botox works by temporarily relaxing overactive muscles that contribute to pain, tension, or involuntary movements, or formation of wrinkles. When the effects wear off after three to four months, muscle activity will gradually return to its natural state.

For Therapeutic Reasons – The muscles will regain their natural function over time, and symptoms may return to their original intensity.

For Cosmetic Reasons - Muscle activity will resume, leading to the reappearance of skin creases and dynamic lines.

What is the ideal age to start Botox treatments?

There is no universally recommended age to begin Botox treatments, but patients must be at least 18 years old. Therefore, preventative treatments for early-stage fine lines and treatments for therapeutic reasons can be initiated at 18 years and older.

When should Botox not be used?

If the patient:

Has an allergy or hypersensitivity to neuromodulators
- Dysport contains lactose as an inactive ingredient in its formulation. The lactose used in Dysport is derived from cow’s milk and serves as a stabilizer for the botulinum toxin.
- While reactions are rare, individuals with severe dairy allergies should consider alternative neuromodulators like Botox or Xeomin, which do not contain lactose.
Has an active infection at the intended injection site
Has a generalized muscle activity disorder
Mysthenis, Gravis, Multiple Sclerosis, Lambert Eaton Syndrome, Amyotrophic Lateral Sclerosis (ALS) or Parkinson’s.
Is currently taking aminoglycoside antibiotics (e.g., Paromomycin, Tobramycin, Neomycin, Gentamicin), as these can interact with neuromodulators
Is pregnant or breastfeeding
- The safety of Botox during pregnancy and breastfeeding has not been conclusively established. Due to the lack of comprehensive studies and potential risks, Botox will not be administered to anyone who is pregnant or breastfeeding.

Can I develop a resistance to Botox?

Although rare, resistance can occur, particularly in individuals who receive frequent, high-dose treatments over an extended period. Studies indicate that 5-10% of patients receiving repeated high-dose botulinum toxin treatments may develop antibodies that reduce the product's effectiveness. However, resistance is estimated to occur in less than 1% of typical cosmetic patients.

To minimize the risk, it is advisable to space out treatments appropriately. If receiving Botox from a neurologist for chronic migraines, scheduling all injections within a two-week window may help reduce overall exposure. If resistance does develop, switching to a different brand or taking an extended break before resuming treatment may improve effectiveness.