Botulinum Toxin for Frontline TMJ Syndrome and Dental Therapeutic Treatment

Transcription

1 Earn 1 CE credit This course was written for dentists, dental hygienists, and assistants. Botulinum Toxin for Frontline TMJ Syndrome and Dental Therapeutic Treatment A Peer-Reviewed Publication Written by Louis Malcmacher DDS MAGD Abstract This article will demonstrate how the use of botulinum toxin is integrated into daily dental treatment in a number of disciplines. Non-surgical, minimally invasive treatment of the muscles of the head and neck is essential for frontline TMJ and myofascial pain therapy as well as treatment of bruxism, removable prosthodontics, orthodontics, periodontics, and implant therapy. Educational Objectives: At the completion of this course, attendees will be able to: 1. List the most important and potentially useful concepts in the use of botulinum toxin in the treatment of TMJ and myofascial pain. 2. Identify whether a patient may be a good candidate for the different treatment options for the use of botulinum toxin for myofascial pain. 3. Describe current concepts in the use of botulinum toxin in the oral and maxillofacial areas. Author Profile Louis Malcmacher DDS MAGD is a practicing general dentist and an internationally known lecturer and author known for his comprehensive and entertaining style. Dr. Malcmacher is president of the American Academy of Facial Esthetics www. FacialEsthetics.org. You can contact him at or [email protected] His website is where you can find information about his hottest topics schedule, live patient Frontline Myofascial Pain training, Botox and dermal fillers training, download his resource list, and sign up for a free monthly e-newsletter. Author Disclosure Dr. Malcmacher is president of the American Academy of Facial Esthetics. Go Green, Go Online to take your course Publication date: May 2013 Expiration date: Apr Supplement to PennWell Publications PennWell designates this activity for 1 Continuing Educational Credit Dental Board of California: Provider 4527, course registration number CA#: This course meets the Dental Board of California s requirements for 1 unit of continuing education. The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2011) to (10/31/2015) Provider ID# This educational activity was developed by PennWell s Dental Group with no commercial support. This course was written for dentists, dental hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content. Requirements for Successful Completion: To obtain 1 CE credit for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products or services discussed in this educational activity. Heather can be reached at [email protected] Educational Disclaimer: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. Image Authenticity Statement: The images in this educational activity have not been altered. Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents the most current information available from evidence based dentistry. Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from the data and information contained in reference section. The research data is extensive and provides direct benefit to the patient and improvements in oral health. Registration: The cost of this CE course is $20.00 for 1 CE credit. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

2 Educational Objectives At the completion of this course, attendees will be able to: 1. List the most important and potentially useful concepts in the use of botulinum toxin in the treatment of TMJ and myofascial pain. 2. Identify whether a patient may be a good candidate for the different treatment options for the use of botulinum toxin for myofascial pain. 3. Describe current concepts in the use of botulinum toxin in the oral and maxillofacial areas. Abstract This article will demonstrate how the use of botulinum toxin is integrated into daily dental treatment in a number of disciplines. Non-surgical, minimally invasive treatment of the muscles of the head and neck is essential for frontline TMJ and myofascial pain therapy as well as treatment of bruxism, removable prosthodontics, orthodontics, periodontics, and implant therapy. The use of botulinum toxin, otherwise known as BoNT-A (Botox, Dysport, Xeomin ), is now routinely used by dentists for treatment of their patients for both dental esthetic, dental therapeutic, and frontline TMJ syndrome and facial pain in the oral and maxillofacial areas. It has been estimated that up to 25% of North American dentists now use BoNT- A in their practices for dental esthetic and therapeutic uses. 1 The American Academy of Facial Esthetics (AAFE) has reported having trained nearly 7000 dental professionals over the last 3 years in the use of BoNT-A for dental esthetic and therapeutic uses. 2 While the use of BoNT-A for esthetic purposes has received a lot of attention in a number of dental journal articles, 3,4,5 BoNT-A pharmaceuticals are excellent agents for dental therapeutic uses in a number of areas. The use of BoNT-A in the oral and maxillofacial areas is really nothing new and one can even find literature dating back almost two decades in this arena. 6 As dentists are now accepting and treating patients with these products for soft tissue cosmetic use to enhance the dental esthetics, BoNT- A neurotoxins are getting much more attention in dentistry than ever before. Certainly, if dentists are going to use these therapies, training is absolutely essential and required both ethically and by state dental boards. Research has certainly shown that BoNT-A is a viable treatment for many facial, TMD, and oral dysfunctions, when they are based in the musculature. BoNT-A products are a conservative, minimally invasive, and relatively painless therapeutic approach to dental, facial, and head and neck areas that have frustrated many dentists over the past 30 years. The safety of these products is well known because of their temporary nature and they are totally reversible over time with generally no lasting effects. Another advantage is that it gives the patient and the dental practitioner the option to stop a therapy at any time and return to the previous state with no ill effects. How BoNT-A works Acetylcholine, as you well may remember, depolarizes the motor end plate of the muscle and will cause a muscle contraction. BoNT-A works by inhibiting the release of acetylcholine at the neuromuscular junction. By inhibiting the release of acetylcholine, BoNT-A effectively will either reduce the intensity of the contraction of the muscle or will eliminate the contraction altogether, depending on the dosage used. Essentially, BoNT-A neurotoxin interrupts the contraction process of the muscles and causes a temporary muscle paralysis. This can last up to three months as the muscle initiates new acetylcholine receptors and the growth of branches from the neurons to form new synaptic contacts. Gradually the muscle returns to its full function and with no side effects whatsoever. 7 When one learns how to use BoNT-A neurotoxin properly, it can be used for a number of dental therapeutic procedures. It can relieve TMJ syndrome and and can retrain muscles which can certainly enhance dental treatment plans as well as help certain disorders that have been frustrating to the dental practitioner for many years. Temporomandibular joint disorder (TMD) It almost seems as if temporomandibular joint disorder is some kind of fad in dentistry that has gone in and out of style. We have been told that 80% of patients have some sort of TMD and need treatment, then it is something that you just don t hear about for awhile. Often, TMD is just a clinical label for any pain of the jaw and facial muscles, which can be associated with headaches, earaches, cervical spine disorders, and general. Treatments that have been used for frontline TMD disorders over the years include doing nothing, psychological therapy, maxillary or mandibular repositioning, orthotic devices, neuromuscular therapy, drug treatments such as anti-inflammatory agents, non-narcotic and narcotic pain medications, spray and stretch, muscle relaxants, chiropractic therapy, massage, acupuncture, and even antidepressants, all with varying levels of success. The use of BoNT-A therapy for TMD symptoms has been in use for many years. 8,9 Along with the introduction of BoNT-A into dentistry, and greater education on trigger points and other minimally invasive treatments, dental clinicians can now offer reversible, successful treatment for TMD patients, providing long term relief. Muscle trigger point therapy Often, with TMD cases, there may be one or multiple trigger points in muscles that a patient points to. Palpating these

3 areas immediately sends a cascading pain along muscle or neuronal tracks that radiate from the trigger point outward. Many agents have been used and injected directly into these trigger points to treat these areas, including sterile saline and local anesthetic. The theory of trigger point injections is that the disruption of the trigger point may be enough to bring some relief, either short term or long term. The success of these treatments have been limited, primarily because the effect of sterile saline or local anesthetic lasts from a few minutes to only a few days. With BoNT-A as the pharmaceutical of choice, trigger point therapy for TMJ syndrome and is now much more effective as well as predictable. For trigger point injections, the use of BoNT-A pharmaceuticals has been highly effective because the effects will last for three months and you are actually helping reduce the intensity of the contraction of the muscle, which is usually in spasm. As dental professionals we may have developed tunnel vision and believe that fixing the dentition will solve all of the other problems. There are many schools of thought in dentistry that an orthognathic approach will work the best with occlusal equilibrations and full mouth reconstructions, which may relieve. This approach has frustrated many dental clinicians and patients as they will finish the case with the occlusal philosophy they have learned and then the patient may still have mild to severe.the muscles themselves may be in need of relief in order to achieve the right occlusal equilibration and end-point for our full mouth reconstruction. In other words, let s treat the muscle pathology symptoms first and then build our occlusion to the relieved muscles so that the will be eliminated. Studies clearly show the relief of painful symptoms in facial muscles with BoNT-A for up to 90% of patients who had not responded to traditional treatments. 10 For and TMD cases, BoNT-A neurotoxins can be generally applied to a number of muscles of facial expression and mastication, including the masseter, temporalis, frontalis, procerus, corrugator, orbicularis oris, orbicularis oculi, mentalis, depressor anguli oris, trapezius, splenius capitus, sternocleidomastoid, and pterygoid muscles. 11 The temporalis and masseter muscles are always treated bilaterally even if only one side of the face is involved. The use of BoNT-A products in TMD therapy can give clinicians a totally new insight into helping these patients who have not found predictable relief in the past. Bruxism Bruxism is the general term that refers to both clenching and grinding of the teeth. There have been numerous theories as to why this occurs and most bruxism will manifest itself nocturnally. Certainly, there are components of psychological stress that may cause it. Regardless of the causes of bruxism, there is no question that it leads to the destruction of otherwise healthy dentition, exacerbates periodontal disease, either causes TMD and is the cause of headaches and. Traditionally, intraoral appliances have been the treatment of choice for bruxism with good success relieving some or all of the symptoms. BoNT-A products can be used to help patients with bruxism. Proper training in the use of BoNT-A neurotoxins is essential. Some clinicians typically treat bruxism and TMD patients with bilateral injections of BoNT-A into the masseter and temporalis muscles. Using the right amount of BoNT-A will reduce the intensity of contractions of these muscles of mastication as well as give your patient full competence for chewing, eating properly, and speaking. The relief afforded to patients by BoNT-A neurotoxins can help eliminate, significantly reduce their TMD symptoms and potentially improve periodontal treatment outcomes by removing the bruxism element. As an example of BoNT-A treatment for both TMJ and bruxism, figure 1 shows a patient who has experienced facial pain and has significant bruxism. The bruxism caused considerable restoration breakage, necessitating replacement. You can see just be looking at this patient that her masseter muscles are in spasm even at rest giving her a square facial appearance. This is not skeletal but is purely a result of masseter hypertrophy. Figure 2 is a close up view of the masseter muscle in spasm. You can see the result of BoNT-A therapy two weeks later in figure 3 - the masseter muscles are no longer in spasm and the patient s face is much more rounded at the corners of the mandible. Her had disappeared and she subsequently has had successful long term dental treatment with BoNT-A injections repeated approximately every 4-6 months to maintain her comfort. Figure 1. Upon observation, bilateral masseter hypertrophy is readily apparent on this patient

4 Figure 2. Close up view of the muscle in spasm. Figure 3. After BoNT-A treatment, the and the masseter hypertrophy are both eliminated. Orthodontic therapy While the role of the facial muscles in determining placement of the teeth is fairly well known, at times dental practitioners may forget about the muscles once the teeth are set after orthodontic therapy has taken place. Relapse has been a continual problem for many general and orthodontic dental practitioners and there are a number of theories as to why this happens. It is readily apparent that some patients have a hyperactive mentalis muscle that may be disrupting the alignment of the teeth. Other muscles in spasm can usually be observed as well with proper training. BoNT-a neurotoxins can reduce muscle contraction intensity and over time it is quite possible that muscles can be trained to work normally.this idea could revolutionize how we deal with orthodontic relapse as dental practitioners become more familiar with the use of BoNT-A neurotoxins. 13 Figure 4. Careful treatment planning and AAFE patient mapping for successful therapeutic outcomes. Figure 5. Live patient one on one mentoring is mandatory for proper BoNT-A continuing education. Masseteric Hypertrophy Masseteric hypertrophy literally means enlargement of the masseter muscles. Most often, this is associated with clenching and bruxism, even when it is mild to moderate. A common treatment for masseteric hypertrophy is BoNT-A injections into the belly of the masseter muscle. 12 This will cause a slenderizing of the face in addition to reducing the intensity of contractions of the masseter muscles and like all other BoNT-A treatments, repeated injections are required every few months. This esthetic effect will happen automatically when BoNT-A is used for TMJ syndrome and bruxism as described above

5 Removable prosthodontics The same idea described in the previous paragraph can be applied to those patients who have trouble getting used to removable prosthodontics. While it is true that more and more patients everyday are receiving implant treatment to help stabilize dentures, there will always be patients who cannot afford implant therapy or because of underlying challenges such as medical history or bone resorption, are not candidates for implant therapy. If you study the facial muscles carefully in patients, you will often times see a hypertrophic masseter and can even feel strong lateral and medial pterygoid muscles that cause the difficulty in adjusting to removable prosthodontics. Muscle training via BoNT-A neurotoxins may someday provide relief as dentists become more familiar with their use. Trigeminal neuralgia Trigeminal neuralgia has frustrated dental clinicians for years and is defined as a unilateral disorder that has recurrent brief, sharp, lancinating pains that are generally limited to the distribution of one or more divisions of the trigeminal nerve. Trigeminal neuralgia is frequently confused with dental pain and needs to be considered more often as a possible diagnosis when all other dental and muscle pathologies have been eliminated as the source of dental and. BoNT-A use is increasing for trigeminal neuralgia cases and while the mechanism of action has not been well established, it has been a useful adjunct to treating these patients as primary or secondary treatment. 14,15 The incidence of trigeminal neuralgia is approximately 1 in 25,000. Adding BoNT-A to the treatment plan may result in significant relief of this disorder. Continuing education a must Because BoNT-A is an injectable pharmaceutical with many oral and maxillofacial therapeutic applications. A frontline TMJ syndrome and course with one on one mentored live patient training as well as the anatomy, physiology, pharmacology, adverse reactions, and potential complications is a must for every dental professional before using BoNT-A. Too often, dentists have been fearful of treating patients with TMJ syndrome and because of the lack of available treatment options. With muscle and trigger point therapy with BoNT-A and other minimally invasive treatments, every dental professional can learn how to successfully treat TMJ syndrome and with these frontline techniques. References 1. Common Sense Dentistry, survey, 2012, www. CommonSenseDentistry.com 2. American Academy of Facial Esthetics private communication, November Niamtu J III. Cosmetic oral and maxillofacial surgery: the frame for cosmetic dentistry. Dent Today. Apr 2001;20: Malcmacher, L. Botox Therapy for Every Dental Practice. Dent Today. August 2009;28: Malcmacher, L. Dermal Filler Therapy for Every Dental Practice. Dent Today. August 2009;28: Ludlow CL, Hallett M. Rhew K, et al. Therapeutic use of botulinum toxin. N Engl J Med. 1992;326: Meunier FA, Schiavo G, Molgo J. Botulinum neurotoxins: from paralysis to recovery of functional neuromuscular transmission. J Physiol Paris. 2002;96: Borodic GE, Acquadro MA. The use of botulinum toxin for the treatment of chronic. J Pain 3(1):21-27, Naumann M, Albanese A, Heinen F, Molenaers G, Relja M. Safety and efficacy of botulinum toxin type A following longterm use. Eur J Neurol 13 (suppl) 4:35-40, Song PC, Schwartz J, Blitzer A. The emerging role of botulinum toxin in the treatment of temporomandibular disorders [reviews]. Oral Dis 13(3):253-60, Kurtoglu C, Gur OH, Kurkcu M, Sertdemir Y, Guler-Uysal F, Uysal H. Effect of botulinum toxin A in myofascial pain patients with or without functional disc displacement. J Oral Maxillofac Surg 66(8): , Kim HJ, Yum KW, Lee SS, Heo MS, Seo K. Effects of botulinum toxin Type A on bilateral masseteric hypertrophy evaluated with computed tomografic measurement. Dematologic Surgery 2003;29(5): Bhogal PS, Hutton A, Monaghan A. Review of the current uses of Botox for dentally-related procedures. Dental Update April 2006;33(3): Piovesan EJ, Teive HG, et al. An open study of botulinum-a toxin treatment of trigeminal neuralgia. Neurology 2005;65: Allam N, Brasil-Neto JP, Brown G, Tomaz C. Injections of botulinum toxin type A produce pain alleviation in intractable trigeminal neuralgia. Clin J Pain 2005; 21: Author Profile Louis Malcmacher DDS MAGD is a practicing general dentist and an internationally known lecturer and author known for his comprehensive and entertaining style. Dr. Malcmacher is president of the American Academy of Facial Esthetics You can contact him at or [email protected] His website is where you can find information about his hottest topics schedule, live patient Frontline Myofascial Pain training, Botox and dermal fillers training, download his resource list, and sign up for a free monthly e-newsletter. Author Disclosure Dr. Malcmacher is president of the American Academy of Facial Esthetics. Reader Feedback We encourage your comments on this or any PennWell course. For your convenience, an online feedback form is available at

6 Online Completion Use this page to review the questions and answers. Return to and sign in. If you have not previously purchased the program select it from the Online Courses listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the Take Exam link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your Verification Form will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page. Questions 1. Botulinum toxin (Botox) can be used for: a. Therapeutic uses only b. Cosmetic and therapeutic uses c. Cosmetic uses only d. Has no use in dentistry at all 2. Botulinum toxin best treats: a. Dynamic wrinkles and pain associated with muscles in motion b. Static wrinkles c. Deep dermal scars d. Acne and herpetic lesions 3. Botulinum toxin can be used for: a. Orthodontic cases b. Removable prosthodontics c. Hearing loss d. A & B 4. TMD pain can be related to: a. Ear infections b. Masticatory or facial muscles in spasm c. Anatomic anomalies in the joint 5. Botulinum toxin s effectiveness is because: a. It is a topical cream that smoothes the skin b. It is injected under the skin to add volume c. The toxin paralyzes the skin so it doesn t move d. The toxin blocks the neurotransmission to the motor muscles which prevents the muscle from moving and allows the skin to smooth out 6. Botulinum toxin can be used as a treatment of: a. Dental caries b. Periodontal disease c. TMJ and bruxism 7. The use of botulinum toxin therapy for TMJ pain symptoms a. has been in use for many years b. has never been used c. should never be used d. has only been in use for 1 year 8. Treating patients for bruxism and muscle related TMJ pain includes injections of which muscles: a. Temporalis and triceps b. Medial pterygoid and sphincter muscles c. Biceps and temporalis d. Masseter and temporalis 9. When pressed, a trigger point: a. Will do nothing b. Will send a cascading pain along muscle or neuronal tracks that radiate outward. c. Will send a tingling sensation without pain to adjacent muscles d. Will send a ticklish sensation down the arm 10. Acetylcholine depolarizes the motor end plate of the muscle and will cause: a. Muscle extension b. Muscle contraction c. The muscle to go to a neutral position d. Nothing to happen 11. Types of frontline TMJ/Oro treatments include: a. Therapeutic exercises b. Bruxism splints c. Spray and stretch 12. When injecting the masseter muscles for TMJ and : a. These muscles are always treated unilaterally b. These muscles are always treated bilaterally c. These muscles are never treated for TMJ and d. These muscles are always treated for TMJ and 13. When injecting the temporalis muscles for TMJ and : a. These muscles are always treated unilaterally b. These muscles are always treated bilaterally c. These muscles are never treated for TMJ and d. These muscles are always treated for TMJ and 14. Often, temperomandibular disorders (TMD) is often a clinical label: a. For any pain in the body b. For any dental pain c. For any pain of the jaw and facial muscles d. For any pain of the ear canal 15. TMD and myofascial pain cases: a. May have only one trigger point b. May have multiple trigger points c. May have no trigger points Notes

7 ANSWER SHEET Botulinum Toxin for Frontline TMJ Syndrome and Dental Therapeutic Treatment Name: Title: Specialty: Address: City: State: ZIP: Country: Telephone: Home ( ) Office ( ) Lic. Renewal Date: AGD Member ID: Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 1 CE credit. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call Educational Objectives 1. List the most important and potentially useful concepts in the use of botulinum toxin in the treatment of TMJ and myofascial pain 2. Identify whether a patient may be a good candidate for the different treatment options for the use of botulinum toxin for myofascial pain 3. Describe current concepts in the use of botulinum toxin in the oral and maxillofacial areas Course Evaluation 1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No Objective #2: Yes No Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = To what extent were the course objectives accomplished overall? Please rate your personal mastery of the course objectives How would you rate the objectives and educational methods? How do you rate the author s grasp of the topic? If not taking online, mail completed answer sheet to Academy of Dental Therapeutics and Stomatology, A Division of PennWell Corp. P.O. Box 116, Chesterland, OH or fax to: (440) For IMMEDIATE results, go to to take tests online. Answer sheets can be faxed with credit card payment to (440) , (216) , or (216) Payment of $20.00 is enclosed. (Checks and credit cards are accepted.) If paying by credit card, please complete the following: MC Visa AmEx Discover Acct. Number: Exp. Date: Charges on your statement will show up as PennWell 6. Please rate the instructor s effectiveness Was the overall administration of the course effective? Please rate the usefulness and clinical applicability of this course Please rate the usefulness of the supplemental webliography Do you feel that the references were adequate? Yes No 11. Would you participate in a similar program on a different topic? Yes No 12. If any of the continuing education questions were unclear or ambiguous, please list them. 13. Was there any subject matter you found confusing? Please describe. 14. How long did it take you to complete this course? 15. What additional continuing dental education topics would you like to see? AGD Code 181, 182 PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. COURSE EVALUATION and PARTICIPANT FEEDBACK We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. Please all questions to: [email protected]. INSTRUCTIONS All questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a verification form. Verification of Participation forms will be mailed within two weeks after taking an examination. COURSE CREDITS/COST All participants scoring at least 70% on the examination will receive a verification form verifying 1 CE credit. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is The cost for courses ranges from $20.00 to $ PROVIDER INFORMATION PennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP at org/cotocerp/. The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2011) to (10/31/2015) Provider ID# RECORD KEEPING PennWell maintains records of your successful completion of any exam for a minimum of six years. Please contact our offices for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt. Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. CANCELLATION/REFUND POLICY Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. IMAGE AUTHENTICITY The images provided and included in this course have not been altered by the Academy of Dental Therapeutics and Stomatology, a division of PennWell Customer Service BOTTOX513DIG