Applications of botulinum toxin in dentistry: A comprehensive review

Comparison of facial profile attractiveness in pattern III patients treated with facial filling or orthognathic surgery

OBJECTIVE

To compare facial profile attractiveness according to orthodontists, dentists, and laypeople in pattern III patients treated with facial filling or orthognathic surgery.

MATERIALS AND METHODS

Thirty pattern III patients were retrospectively divided into two groups. Group 1 comprised 15 patients (10 females, five males; mean age 37.40 years, SD = 14.50) treated with a hyaluronic acid facial filling. Group 2 comprised 15 patients (seven females, eight males; mean age 31.76 years, SD = 9.85) treated with dental decompensation and orthognathic surgery. Facial profile silhouettes from photographs were evaluated by laypeople (n = 80), dentists (n = 60), and orthodontists (n = 68), who rated attractiveness on a scale from 0 (least attractive) to 10 (most attractive). Profile attractiveness was compared between groups using independent t-tests. Evaluator group scores were compared using one-way ANOVA and Tukey tests.

RESULTS

Both the facial filling and surgery groups significantly improved profile attractiveness. Initially (T1), both groups had similar profile attractiveness. Post-treatment (T2), the surgical group had a significantly more attractive profile than the facial filling group. Orthodontists recorded the highest profile attractiveness ratings, dentists gave intermediate scores, and laypeople recorded the lowest, both before and after treatment. Correct answer percentages were similar across the evaluator groups for both treatments.

CONCLUSION

Both treatments significantly improved profile attractiveness, with the surgical group showing greater improvement.

A Systematic Review and Comparative Analysis of Botox Treatment in Aesthetic and Therapeutic Applications: Advantages, Disadvantages, and Patient Outcomes

The objective of this review article is to comprehensively analyze Botox treatment, emphasizing its aesthetic and therapeutic applications, along with the associated advantages, disadvantages, and patient outcomes. By reviewing current literature, the article evaluates Botox's efficacy and safety in various clinical settings, including cosmetic procedures and medical treatments for conditions such as chronic migraines and excessive sweating, while also exploring patient satisfaction and potential risks. This review article provides a comprehensive analysis of Botox treatment, focusing on its aesthetic and therapeutic applications, as well as the associated advantages, disadvantages, and patient outcomes. Botulinum toxin, derived from Clostridium botulinum, is widely recognized for its ability to induce temporary muscle paralysis, leading to significant improvements in both cosmetic and medical conditions. The article reviews findings from recent clinical trials, case reports, and observational studies, highlighting the efficacy and safety of Botox in treating various conditions such as chronic migraines, excessive sweating, and muscle spasticity, alongside its cosmetic use in wrinkle reduction. While the benefits of Botox are substantial, including its minimally invasive nature and high patient satisfaction rates, potential risks and complications, including rare adverse events, are also discussed.

Use of botulinum neurotoxin Type A in the management of primary bruxism in adults: An updated systematic review

STATEMENT OF PROBLEM

The psycho-emotional effects caused by the coronavirus pandemic have increased the intensity and number of cases of bruxism, for which no treatment has been considered fully effective. Botulinum neurotoxin Type A (BoNT-A) has shown positive results as an adjunct treatment of primary bruxism; however, this off-label use does not have an established protocol, and further studies are required.

PURPOSE

The purpose of this updated systematic review was to analyze the clinical outcomes of BoNT-A in the management of primary bruxism in adults.

MATERIAL AND METHODS

The review was registered under the International Prospective Register of Systematic Reviews (PROSPERO) registration number CRD42021287653, without funding. PubMed, Web of Science, Scopus, LILACS, Cochrane Library, and Open Grey Literature databases were searched by using the Mendeley Desktop software program without language restrictions up to June 6, 2021. The risk of bias of the selected randomized clinical trials was assessed by using RoB2, and the level of evidence was measured by 2 independent researchers using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool.

RESULTS

A total of 741 references were obtained from the 6 databases in this systematic review. The 11 randomized clinical trials selected achieved a reduction in bruxism symptoms by injecting BoNT-A into 211 participants with different protocols. The heterogeneity of the included studies did not permit a meta-analysis.

CONCLUSIONS

All the evaluated studies supported the effectiveness of BoNT-A injections in reducing bruxism symptoms. The reduction of symptoms can be obtained with doses lower than 25U applied exclusively in the masseter muscles.

Botulinum Toxin Type A and Hyaluronic Acid Dermal Fillers in Dentistry: A Systematic Review of Clinical Application and Indications

Background

Botulinum toxin type A (BoNT-A) and hyaluronic acid (HA) dermal fillers are increasingly utilized in dentistry for therapeutic and aesthetic purposes. However, a comprehensive synthesis of their clinical applications and indications in dentistry is lacking. This systematic review aimed to analyze the clinical application and indications of BoNT-A and HA dermal fillers in dentistry, providing insights into their efficacy, safety profiles, and limitations.

Methods

A systematic search was conducted in PubMed/MEDLINE databases to identify relevant studies published between 2018 and 2024. Medical Subject Headings (MeSH) terms and keywords related to BoNT-A, HA dermal fillers, dentistry, clinical applications, and indications were used. Study selection criteria included randomized controlled trials (RCTs) and non-RCTs involving human participants of any age group. Data extraction and synthesis followed established guidelines, focusing on study characteristics, participant demographics, intervention details, outcome measures, and key findings related to BoNT-A and HA dermal fillers' clinical application in dentistry.

Results

Systematic searches across electronic databases and grey literature identified 857 records, with an additional 73 from hand searches. After screening titles and abstracts, 542 records were excluded, leaving 374 full-text publications for evaluation. Ultimately, 12 RCTs and 13 non-RCTs were included. The systematic review encompassed diverse geographic locations: Brazil, Italy, Spain, Syria, India, Egypt, Korea, and the Netherlands, involving samples sizes ranging from 14 to 143 participants. The review synthesized findings on HA's efficacy in various areas, including bone repair, gingivitis management, temporomandibular joint disorders, postoperative swelling reduction, periodontal defect treatment, chin and check projection and lips augmentation. BoNT-A exhibited promising efficacy in managing orofacial pain conditions, gummy smile treatment and neuromodulation of the lower third muscles. Safety profiles varied among studies, with some reporting minimal adverse effects while others noted dose-related concerns.

Conclusion

BoNT-A and HA dermal fillers offer a wide array of clinical applications in dentistry, ranging from therapeutic interventions to aesthetic enhancements. Despite promising efficacy, careful consideration and monitoring of safety outcomes are essential when integrating these interventions into clinical practice. Further research addressing methodological limitations and safety concerns is warranted to optimize their utilization and improve patient care in dentistry.

Velopharyngeal Insufficiency After Botox Injection for Persistent Bruxism

Botulinum toxin type-A (BTX-A) injections have emerged as a promising treatment for bruxism and temporomandibular joint (TMJ) disorders. However, there is a need for further exploration of optimal dosage, injection techniques, and intervals to maximize treatment effectiveness. Complications, such as velopharyngeal insufficiency, can occur after BTX-A injections, emphasizing the importance of precautionary measures. The utilization of ultrasound guidance and electromyography assistance can aid in precise injections and minimize the risk of complications. In addition, patients should receive appropriate medication and adhere to post-treatment instructions to alleviate symptoms. Follow-up procedures are essential to monitor potential complications, and in some cases, professional mental health care may be required. Further research is warranted to establish the safety and efficacy of BTX-A injections for the treatment of bruxism and TMJ disorders. This case study presents the development velopharyngeal insufficiency in a patient with chronic bruxism 3 days after receiving a BTX-A injection.

Natural Products and Pharmacological Properties of Symbiotic Bacillota (Firmicutes) of Marine Macroalgae

The shift from the terrestrial to the marine environment to discover natural products has given rise to novel bioactive compounds, some of which have been approved for human medicine. However, the ocean, which makes up nearly three-quarters of the Earth's surface, contains macro- and microorganisms whose natural products are yet to be explored. Among these underexplored marine organisms are macroalgae and their symbiotic microbes, such as Bacillota, a phylum of mostly Gram-positive bacteria previously known as Firmicutes. Macroalgae-associated Bacillota often produce chemical compounds that protect them and their hosts from competitive and harmful rivals. Here, we summarised the natural products made by macroalgae-associated Bacillota and their pharmacological properties. We discovered that these Bacillota are efficient producers of novel biologically active molecules. However, only a few macroalgae had been investigated for chemical constituents of their Bacillota: nine brown, five red and one green algae. Thus, Bacillota, especially from the marine habitat, should be investigated for potential pharmaceutical leads. Moreover, additional diverse biological assays for the isolated molecules of macroalgae Bacillota should be implemented to expand their bioactivity profiles, as only antibacterial properties were tested for most compounds.

Mechanism and clinical use of botulinum neurotoxin in head and facial region

PURPOSE

Botulinum neurotoxin (BoNT) is a biological toxin produced by Clostridium botulinum. BoNT is a potent toxin extensively used in therapeutic interventions. This review provides an updated overview of the mechanisms of action and clinical applications of BoNT in head and facial region.

STUDY SELECTION

MEDLINE/PubMed searches were conducted using the terms "botulinum neurotoxin" and "dentistry" along with a combination of other related terms. In addition, studies were manually selected from reference lists of the selected articles.

RESULTS

The Food and Drug Administration in the United States initially approved BoNT to treat strabismus, blepharospasm, and hemifacial spasms. The use of BoNT in dermatology and cosmetics has been widely established and has created a revolution in these fields. Over the years, its applications in various medical specialties have expanded widely. Owing to its safety, efficacy, and long duration of action, it is well-accepted by patients. BoNT/A and BoNT/B are widely used in clinical practice. Several off-label uses of BoNT in the dental fraternity have yielded promising results. We have elaborated on the speculated mechanism of action, dosage, effective sites of injection, and adverse effects of each therapeutic application. The various clinical indications for BoNT include bruxism, myofascial pain, temporomandibular joint dislocation, hemifacial pain, orofacial dystonia, facial paralysis, chronic migraine, and trigeminal neuralgia.

CONCLUSIONS

BoNT is a safe treatment that can be used effectively, provided that the clinician has adequate knowledge regarding the mechanism, injection techniques, and local and systemic side effects and that it is administered cautiously and purposefully.

Bruxism and Botulinum Injection: Challenges and Insights

Botulinum toxin (BTA) is a bacterial-derived extract that can inhibit muscle contraction, acting directly on the absorption of acetylcholine. Thanks to this property, botulinum has been used in aesthetic and general medicine for several years. Nowadays, the use of botulinum toxin is being deepened to address the problem of bruxism. In this scoping review, the results of the studies in the literature of the last 10 years were analyzed. Indeed, 12 reports (found on PubMed, Web of Science, and Scopus, entering the keywords "BRUXISM" and "BOTULINUM TOXIN") were deemed eligible for inclusion in this review. In the studies reviewed, BTA was injected into different muscle groups: masseters, masseter and temporalis or masseter, temporalis, and medial pterygoid. Botulinum toxin injection is a viable therapeutic solution, especially in patients with poor compliance or without improvement in conventional treatment.

Effects of lidocaine incorporation (without epinephrine) on pain and 2-week complications of botulinum toxin: a double-blind randomized placebo-controlled clinical trial

No study has assessed the effects of the incorporation of isolated lidocaine into botulinum toxin for reducing its pain or complications. Studies on the dilution of botulinum toxin with other materials are as well extremely few, small, and limited methodologically. Therefore, we aimed to evaluate, for the first time, the effects of the incorporation of lidocaine alone into botulinum toxin type A on post-injection pain and complications. In this 2-week prospective, multicenter, double-blind randomized placebo-controlled clinical trial, 729 participants (667 females) were enrolled. They were randomized into placebo and lidocaine dilutions (about 2:1), and then into two brands of toxins (Dysport versus Xeomin). Hence, there were 4 subgroups. In the 2 experimental subgroups, botulinum toxin was diluted with 2% lidocaine without adrenaline; in the 2 control subgroups, botulinum toxin was diluted with normal saline as a placebo. After injection, the pain level was recorded (as an 11-scale numerical rating scale from 0 to 10). After 2 weeks, post-injection complications were assessed based on the participants' reports and the surgeon's observations. Data were analyzed using 3-way ANCOVA, multiple binary logistic regression, and bivariable analyses (α = 0.05, β ≤ 0.1). The mean ± SD pain levels in the lidocaine group (n = 263) and the placebo group (n = 466) were 3.51 ± 2.04 and 4.15 ± 2.35, respectively. The mean ± SD pain levels in the subgroups 'Xeomin-Lidocaine (n = 61), Dysport-Lidocaine (n = 202), Xeomin-Placebo (n = 133), and Dysport-Placebo (n = 333)' were respectively 3.39 ± 1.86, 3.55 ± 2.09, 4.61 ± 2.49, and 3.97 ± 2.24. Lidocaine incorporation (P = 0.001), Dysport brand (P = 0.030), and younger age (P = 0.032) [but not sex (P = 0.406)] reduced pain. The only significant findings for 2-week complications were for the associations observed between aging with increased asymmetry (P = 0.022, OR = 1.032) and a need for a retouch (P = 0.039, OR = 1.021). Botulinum toxin dilution with lidocaine alone (without adrenaline or other ingredients) can reduce pain without affecting postinjection complications. Toxin brands may cause different extents of pain. Aging, but not sex, may increase pain. Two-week complications were not affected by any factors, except aging in the case of asymmetry and the need for a botulinum toxin retouch.

Preliminary Findings of the Efficacy of Botulinum Toxin in Temporomandibular Disorders: Uncontrolled Pilot Study

Temporomandibular disorders are a common pathology affecting up to 70% of the population, with a maximum incidence in young patients. We used a sample of twenty patients recruited in the Maxillofacial Surgery Service of the University Hospital of Salamanca (Spain), who met the inclusion criteria, with unilateral painful symptomatology of more than three months' duration. All patients were randomly treated by intramuscular and intra-articular injections of botulinum toxin (100 U) in eight predetermined points. Pain symptomatology was assessed by the visual analog scale (VAS) at the different locations, together with joint symptomatology, at baseline and six weeks after treatment. Adverse effects were also evaluated. In 85% of the patients, pain upon oral opening improved and 90% showed improvement in pain upon mastication. A total of 75% of the patients reported improvement in joint clicking/noise. Headaches improved or disappeared in 70% of the patients treated. Despite the limitations of the study and the preliminary results, intramuscular and intra-articular infiltrations with botulinum toxin were effective in the treatment of symptoms associated with temporomandibular disorders (TMDs), with minimal adverse effects.

Effectiveness of Botulinum Toxin Injection on Bruxism: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

The present study compiled evidence on the efficacy of botulinum toxin A (BTX) for management of bruxism.

METHODS

A literature review that included randomized control, cohort, as well as observational studies published between January 2000 and November 2022 was conducted. All studies related to BTX injections administered into the masseters of patients with bruxism were included. Primary outcomes were measured by performing a meta-analysis of changes in maximal biting forces and pain severity and meta-regression of the effects of the BTX dose.

RESULTS

Ten studies were included for quantitative analysis. The analysis of the maximal biting force after BTX injections demonstrated a significant reduction at 1 month or less compared with both oral splints (P < 0.000001) and saline injections (P = 0.01). BTX continued to outperform oral splinting (P = 0.001) and saline placebos (P = 0.03) at 3 months. Between 3 and 6 months, a significantly higher maximal biting strength was observed in the BTX group than the oral splinting group (P < 0.00001). No significant differences in the maximal biting force were observed between the BTX and saline placebo groups (P = 0.50). A similar trend was observed in the analysis of pain reduction after botulinum treatment. Additionally, for every unit increase in the BTX dose, pain severity decreased by 0.0831 points (P = 0.0011).

CONCLUSION

BTX is effective in reducing biting strength and pain severity. BTX effects are evident at less than 4 weeks, peak between 5 and 8 weeks, and last for up to 24 weeks. Higher BTX doses result in greater improvement in pain. Although BTX benefits manifest earlier, they gradually diminish, and oral splinting exerts a more enduring effect, especially after 9-12 weeks. BTX injections into masseters are recommended as management options for bruxers, especially for those having difficulties complying with wearing oral splints or those seeking earlier symptom relief. However, future studies should determine BTX effects beyond 24 weeks and after repetitive injections and how bruxers of different ages or genders respond to treatment.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Botulinum Toxin, a Drug with Potential Interest for Dentists—An Introduction

The review is an introduction to medical, non-cosmetic treatments with botulinum neurotoxin (BoNT) in the orofacial region. It focuses on the current most common, best-documented and safest indications of interest for dentists in terms of dystonia and sialorrhea. These conditions are recommended to start with and suitable to gain better skill and experience with BoNT. The introduction also stresses the importance of correct diagnostics based on interdisciplinary cooperation, precise targeting of the injections, measurements of treatment effect, and control of the oral health with regard to side effects.

Botulinum toxin A in dentistry and orofacial surgery: an evidence-based review - part 1: therapeutic applications

Objective An evidence-based review on the safety and efficacy of botulinum toxin type-A (BoNTA) in orofacial conditions, focusing on the therapeutic applications and role of BoNTA as an adjuvant treatment.Data source and selection Data was collected using PubMed (Medline), Cochrane Library of Systematic Reviews and Cochrane Central Register of Controlled Trials electronic databases. Having satisfied the search parameters, 32 studies for therapeutic applications and 26 for BoNTA as an adjunctive treatment were included. The quality of relevant studies was assessed using the Best Evidence Topics (BETs) Critical Appraisal Tool.Data extraction The highest level of evidence (LOE) behind BoNTA safety and efficacy was for wound healing and scar management in the orofacial surgery context, where BoNTA was presented as an adjunctive modality. Level-I evidence was controversial for temporomandibular disorders and bruxism. However, it showed promising results for painful temporomandibular disorders of myogenic origin refractory to conservative therapies, and to decrease muscle contraction intensity in sleeping bruxism. There was only one level-II study for persistent recurrent aphthous stomatitis. Data showed limited level-III evidence for orofacial pain conditions (temporomandibular joint recurrent dislocation and pain, burning mouth syndrome or atypical odontalgia), oral cancer complications, or as an adjuvant to maxillofacial and orthognathic surgeries. Benefits of BoNTA in prosthodontics had weak level-IV evidence. No evidence was found among the periodontology field.Conclusion There is growing evidence to support the safety and efficacy of BoNTA in the investigated orofacial pathological conditions, with high levels of satisfaction from the patient and clinician perspective. However, there are some inconsistencies and limited high-quality evidence available. Well-designed controlled clinical trials are necessary to evaluate long-term safety, efficacy and cost-effectiveness before BoNTA is widely adopted with irrefutable evidence-based clinical guidelines.

A Standardized Technique for Gummy Smile Treatment Using Repeated Botulinum Toxins: A 1-year Follow-up Study

The present study was performed to evaluate the effect of repeated botulinum toxin injections and their long-term effects, using a customized injection point and dosage technique in the treatment of excessive gingival display. Twenty women who had gummy smile due to hypermobility of the upper lip or gingival display, ranging from 4 to 6 mm' were included in the study. All patients were injected with Botox injections at different injection points according to the type of smile. Pre- and postoperative measurements were taken by measuring digitally the gingival display at smiling, using Adobe Photoshop software via standardized digital photographs. Patients were followed up at 14 days, 4 months, 8 months, and 12 months. Postoperative measurements showed marked improvement at 14-day follow-up, with a significant reduction in the amount of gingival display. Relapse, however, occurred at 4 months and later. For excessive gingival display, Botox is an effective treatment that lasts for 2-3 months, with almost complete relapse at 4 months. We concluded from the results of our study that, despite repeated Botox injections at two follow-up intervals (4 and 8 months), the theory that repeated Botox injections may offer a permanent effect is still questionable.

Attitude of Thai Dental Practitioners towards the Use of Botulinum Toxin in Dentistry

This study aims to investigate the attitude of Thai dentists towards the use of botulinum toxin (BTX) in dentistry and the associated factors. An online survey was conducted using a semi-structured questionnaire consisting of four parts: demographic data, background knowledge, attitude, and an open-ended question for further suggestions related to BTX usage in dental patients. Multivariate logistic regression was used to analyze factors that affect the decision to use BTX in dentistry, and a content analysis approach was used to describe open-ended suggestion data. We received 444 responses from currently practicing dentists throughout Thailand. Roughly 80% of the participants agreed to the use of BTX in their patients. Most participants were aware that BTX could be used for facial esthetic repairs and bruxism treatment but unaware of other therapeutic benefits. Despite impressively positive attitudes towards BTX use, only 5.9% of the participants had the experience of using BTX in their dental patients. The limit on BTX use is mainly due to the lack of knowledge of related laws and educational resources. In summary, official training courses should be established to promote the safe and legal use of BTX in dentistry in Thailand.

Clinical outcomes of botulinum toxin type A injections in the management of primary bruxism in adults: A systematic review

STATEMENT OF PROBLEM

Botulinum toxin has been used for various therapeutic and esthetic purposes for nearly 4 decades and has shown positive outcomes in patients with bruxism. However, the effectiveness of botulinum toxin injections as an alternative to traditional therapies in the management of primary bruxism is still unclear.

PURPOSE

The purpose of this systematic review was to analyze the clinical outcomes of the use of botulinum toxin type A injections in the management of primary bruxism in adults.

MATERIAL AND METHODS

Databases such as PubMed, Web of Science, Scopus, LILIACS, Cochrane Library, and Open Grey Literature were searched without language or date restrictions until October 6, 2019. Using Mendeley Desktop software to organize the references, 2 independent researchers selected the published clinical studies (Study type) on the improvement of symptoms (Outcome) in human adults with primary bruxism (Participants/Population) who received botulinum toxin type A injections (Intervention), placebo injections, saline injections, no injections, or other treatments (Comparator(s)/Control) for the management of bruxism.

RESULTS

A total of 601 references were initially obtained from the 6 databases. Six randomized clinical trials and 4 case series were selected and critically appraised according to the Fowkes and Fulton guidelines. Heterogeneity among the studies did not allow for a meta-analysis. All studies supported the efficacy and safety of botulinum toxin injections in reducing the symptoms of primary bruxism.

CONCLUSIONS

Botulinum toxin type A injections are effective in the treatment of the symptoms of primary bruxism in adults. Randomized clinical trials are still needed to establish a protocol for using botulinum toxin as an alternative to traditional therapies in the management of primary bruxism.

Masticatory hypofunction effects induced by BTXA injection of hippocampal neurons in developing rats

BACKGROUND AND OBJECTIVE

In clinical practice, malocclusion is often encountered during the period of growth and development of individuals. In addition to nutritional imbalance, some studies have found that mastication affects learning and memory ability. Tooth loss and masticatory hypofunction have been suggested as risk factors of Alzheimer disease. However, relatively little research has been done in developing animals. The present study evaluated the relationship between masticatory hypofunction and neuropathological changes of the hippocampus in developing rats.

DESIGN

Four-week-old Wistar rats were randomly divided into saline-injected and botulinum toxin type A (BTXA)-injected groups. After an experiment period of 4 weeks, the rats were sacrificed for evaluation of neuropathological changes in the hippocampus through Nissl staining and phosphorylated cyclic AMP (cAMP) response element binding protein (CREB) immunohistochemistry.

RESULTS

Nissl staining revealed a significant reduction in the density of neurons in the BTXA-injected rats. The BTXA-injected rats exhibited a decreased level of CREB phosphorylation. The degree of p-CREB immunoreactivity differed significantly between the two groups.

CONCLUSION

The BTXA-injected rats exhibited a reduction in neuron density and phosphorylated CREB, indicating that mastication might influence the learning and memory ability during the growth period. Therefore, it is strongly suggested that malocclusion be corrected as soon as possible during growth and development.

Evaluation of the rivastigmine role against botulinum toxin-A-induced osteoporosis in albino rats: A biochemical, histological, and immunohistochemical study

The present study aimed to evaluate the role of rivastigmine against the effect of a single unilateral botulinum toxin-A (BTX-A) injection on the bone and bone marrow of adult albino rats 4 weeks after injection. Twenty-four Wistar albino rats were divided into four equal groups: group I, which received distilled water; group II, which received rivastigmine (0.3 mg/kg daily, intraperitoneally for 4 weeks); group III, which received BTX-A (4 IU in 0.2 mL physiological saline) single dose, intramuscularly; and group IV, which received BTX-A + rivastigmine. The results revealed that BTX-A induced a significant decrease in the calcium level with a significant increase in the phosphorus, alkaline phosphatase, C-reactive protein, and tumor necrosis factor α levels in serum. Furthermore, a significant increase in malondialdehyde with a significant decrease in reduced glutathione activities in both bone and bone marrow. Histologically, a distortion and thinning out of the compact bone and trabeculae of cancellous bone of the rat femur in the BTX-A group with an increase in adipocytes in adjacent bone marrow were detected. Immunohistochemically, Cluster of Differentiation 68 (CD68) showed a significant increase in both osteoclasts and bone marrow macrophage. Rivastigmine treatment could relieve the toxic effects induced by BTX-A. In conclusion, rivastigmine has a protective effect against the hazardous effects of BTX-A on bone and bone marrow.