Bradley D. Becker, DDS, PA
Charles G. Liggett, DDS, PA
3324 Old Greenwood Road
Fort Smith, AR 72903
479-646-0706
I request that Dr. Liggett DDS perform BOTOX injections into salivary glands on my
cheeks and in my mouth, and/or into the muscles of my face.
Indications and Alternatives
BOTOX is a brand name for botulinum toxin type A, a neurotoxin that blocks messages
between muscles and the nerves that control them. The temporary effects of BOTOX
become apparent 2-5 days after injection and generally last for 4-6 months. The FDA has
approved the use of BOTOX to treat facial muscle dystonias (spasms), strabismus
(crossed eyes), and the temporarily soften facial rhytids (wrinkles) between the eyebrows.
While the FDA has not approved injection to treat dentally related conditions in other
areas of the face, physicians or dentists may perform these “off-label” procedures. There
are alternatives to BOTOX, including; no treatment, other injectable or ingestible drugs,
orthodontics, reshaping the teeth, medicines, or surgery on my jawbones, facial nerves
and muscles.
I acknowledge that Dr. Liggett has explained the following to my satisfaction:
 There is no guaranteed treatment method available for diminishing or “curing”.
 The Federal Drug Administration has not approved the use of Botulinum toxin for
treatment of headaches, TMJ, neck/back pain, or reducing salivary flow.
 BOTOX treatments have a temporary effect and serial treatments may be required
to maintain results, or attain further improvement.
 BOTOX treatments can be costly and probably will not be covered by insurance
at this time.
Signature
1