Sir, I work in general practice and came across a 60-year-old female patient who presented as an emergency in pain. I diagnosed acute apical periodontitis associated with the 33. After assessing her treatment options, patient choice was extraction. The interesting point to note was that the patient had significant bilateral jaw tremor (dystonia) secondary to Parkinson's. This was significantly more pronounced than the classic hand tremor associated with Parkinson's. This can often make dental treatment difficult to perform in a general practice not set up for sedation.

The patient reported that lignocaine-based anaesthetics tend to exacerbate her jaw tremor and so we opted for prilocaine. She also reported that her neurologist had obtained funding enabling him to inject botox into the facial muscles. On further questioning, she was adamant that this was a procedure being provided by her neurologist and not the maxillofacial team. C. Pedemonte et al. in 2015 reported a reduction in the signs and symptoms associated with oromandibular dystonia (bruxism, muscle pain and involuntary muscle contraction) with the application of botulinum toxin A.1 This raises the question of the scope of the application of botox and who should be providing it, especially where there is an overlap between our maxillofacial colleagues and neurologists in complex cases such as this. Furthermore, it raises the question of the effects different local anaesthetics have in patients with Parkinson's with dystonia. It seems that some clarity and guidelines are needed.