BOTOX® THERAPY FOR EVERY DENTAL PRACTICE
To say that Botox® is a popular esthetic treatment is a vast understatement. Over 21 years has past since the introduction of botulinum toxin A injections (Botox®) have been used for the unsightly frown lines between the eyes and smoothing of facial wrinkles. Botox® treatments are the most commonly performed minimally invasive cosmetic procedure in North America. There were nearly 2.5 million cosmetic procedures done with Botox® in 2008 according to The American Society of Aesthetic Plastic Surgery. Women accounted for 92% of the total cosmetic procedures done. Botox® cosmetic procedures accounted for 24% of all cosmetic procedures done in 2008. The safety records of Botox® treatment is nearly unparalleled by just about any other delivered medication on the market.
THE QUICK BOTOX® PRIMER
Botox® is a trade name for botulinum toxin, which comes in the form of a purified protein. Botulinum toxin A is the most commonly used form with a few thousand articles supporting its use in scientific and medical literature. The mechanism of action for botulinum toxin A is really quite simple. It is injected into the facial muscles and, within a few hours, it attaches itself to the nerve endings of the motor muscles, thereby affecting the nerve transmission to these muscles. It takes anywhere from two to ten days to block the nerve transmitters which innervate the muscles where it was injected. There is no loss of sensory feeling at all during the time that botulinum toxin A is effective. Once these motor nerve endings are interrupted, the muscles cannot contract. When the muscle does not contract, the dynamic motion that causes wrinkles in the skin will then cease. The only reason there are wrinkles in the skin in the first place is because the muscle is moving underneath it, thereby these are called dynamic wrinkles. Approximately three to ten days after treatment, the skin above these motor muscles becomes nice and smooth. The effects of Botox® lasts approximately three to four months depending on various factors including the amount of botulinum toxin A injected, metabolic activity of the patient and lifestyle choices, which may cause the Botox® treatment not to last as long. When the patient sees the wrinkles reappear, the patient needs retreatment.
This is one of the reasons that Botox® has such an incredible safety record. Botulinum toxin A treatment by its nature is a temporary treatment and when the treatment effects are gone, they are gone completely. This is a little different than the usual mindset of dentists. We as dentists don’t usually think of our treatments as temporary. The most common dental treatment that is like Botox® therapy is teeth whitening. Teeth whitening is a temporary procedure that needs to be refreshed from time to time.
The most common uses for Botox® is smoothing of the facial wrinkles of the forehead, between the eyes (glabellar region) and around the corners of the eyes (crow’s feet) (figures 1-5). These are the most common cosmetic uses that have put Botox® on the esthetic map.
DENTAL USES FOR BOTOX®
Now that approximately 7% to 8% of dentists (and growing) in North America are now providing Botox® treatment to patients for cosmetic treatment, there are other innovative uses being found for Botox® in dentistry. Most dentists are not aware of the substantial benefits that Botox® has as an adjunctive therapy in dental and cosmetic treatment. Botox® has useful clinical uses as an adjunct in TMJ and bruxism cases, even more so for patients with moderate chronic temporomandibular joint and facial pain. Botox® is a muscle relaxer and when given in typically half the dosage used for facial wrinkle smoothing treatment, it can greatly reduce the intensity of the muscle contractions that contribute to TMJ and facial pain and give the patient significant relief. We have all had TMJ patients that have gotten the bruxism appliances, have done full mouth reconstructions, and are still at wits end at trying to find the right answer that will help them with their facial pain. Botox® can play a very important role in reducing or eliminating their facial pain.
Botox® is often used in conjunction with dermal filler therapy as a non-surgical alternative to high lip line cases. Figures 6 and 7 describe such a case. This patient has a nice smile with a significantly high lip line showing on the left side of her mouth when she smiles. The treatment that most dentists have been trained to deliver to these patients would be some kind of periodontal flap surgery with significant osseous reduction through a crown lengthening procedure in order to be able to raise the gingival height to meet the lip line. The patient would then require crown and bridge therapy to better establish the dental esthetics. Every dentist knows how aggressive that treatment would be. I would venture to say that few dentists themselves would, if they were the patients, want to proceed with that kind of aggressive treatment, yet this is what we offer to our patients. With some Botox® therapy and lip augmentation with dermal fillers, the muscles surrounding the lip are weakened so they cannot raise the lip as high as before. This has to be done carefully so that the patient maintains full lip competency allowing them to go about their normal activities such as speaking, smiling, puckering, and eating. When done correctly, the patient is not able to raise her lip as high as before to show the gingiva on the left side, but still has the full ability to speak, chew and kiss.
It is important to be able to offer all of the alternatives to the patient for high lip line cases. The advantages of the aggressive treatment option of crown lengthening, possible orthodontics, and crown and bridge therapy, the results will be long lasting and can be esthetic. The disadvantages are the treatment will take a number of appointments, high cost immediately, possible complications of said treatment including sensitivity, possibly requiring endodontic therapy later on, and necessary re-treatment in 10-15 years as gingival recession occurs. The advantages of treating cases like the one above with Botox® and dermal fillers are close to immediate results in one appointment and no removal of tooth structure. The disadvantages are needed re-treatment 2-3 times a year and the cost associated with that treatment. It makes no difference to me as the clinician which the patient chooses but it significantly expands the treatment choices we now have in dentistry.
A BEAUTIFUL SMILE, NOT JUST BEAUTIFUL TEETH
The above case demonstrates how much Botox® and dermal fillers are as essential to esthetic dentistry cases as are porcelain veneers and composite resins. The soft tissues around the mouth are as important as the color and position of the teeth in determining the patient’s smile. We, as dentists, have become so teeth-centric that we forget that we also need the perioral areas around the mouth to look as good as the teeth for complete smile analysis and esthetic treatment. How many times have you seen a beautiful esthetic dental case only involving teeth that are surrounded by wrinkled and thin lips and deep nasolabial folds? I would submit that you may have given the patient beautiful teeth but you have not given them a beautiful smile.
Botox® has also been used in other areas of dentistry including retraining muscles during orthodontic therapy. Orthodontically, you can move the teeth all you want but if you have strong to severe muscle movement, teeth will relapse, especially patients with a very strong mentalis muscle. Botox® can be used to reduce the intensity of the muscle post treatment and over time, the muscle may be retrained to a more physiological movement. Again, this is adjunctive therapy but is a nice option for patients that have had significant orthodontic relapse due to a hyperactive muscle.
Botox® can also be used in patients as they get used to new dentures, especially with patients who have been edentulous for a long time and have old dentures and they are significantly overclosed. The dentures you make for patients may fit perfectly but with strong irregular muscle contractions, the patients will have a hard time getting used to their dentures and keeping in their mouths..
As people get older, the corners of the mouth begin to turn down. Botox® can be placed in the depressor anguli oris muscles bilaterally to relax these muscles which will in turn raise the corners of the mouth. Botox® can also be used to smooth the wrinkles around lips that are very commonly called smokers’ wrinkles. These wrinkles may not have anything to do with smoking, but have everything to do with the strong contractions of the orbicularis oris muscles.
DENTISTS ARE THE ORAL AND MAXILLOFACIAL “SPECIALISTS”
There is a huge misconception and much confusion that Botox® therapy is not within the realm of dentists and dentistry. Nothing could be further from the truth. Right now close to half the states in the US and some provinces in Canada allow dentists to perform Botox® procedures in all of the oral and maxillofacial areas. In other states, state dental associations are lobbying to allow dentists to begin performing these procedures. Certainly, as demonstrated in this article, the uses for Botox® in dental treatment are within the scope of dental practice as defined by most state dental boards. Readers are urged to become familiar with their state dental board laws regarding the definition of the scope of practice for dentistry in their locations.
With plastic surgeons, dermatologists, internal medicine physicians, OB-Gyns, opthamologists, podiatrists, nurses, physicians’ assistants, and medical estheticians (who may not even be medically trained), delivering Botox® to patients in the oral and maxillofacial areas, it is certainly time to recognize that dentists are much more proficient in injections than any of these healthcare providers. Dentists are also the specialists in the oral and maxillofacial areas. We are much more knowledgeable than most other healthcare providers in the muscles of mastication and the muscles of facial expression which routinely receive these treatments.
Dentists are sometimes afraid that Botox® and dermal fillers belong in medical arena and only physicians should perform these procedures. First of all, we are part of the medical arena and we are “real doctors”. Every time you inject local anesthetic into a patient, you are delivering a medicinal agent into the body that has real systemic complications. The only difference is that you have learned and been trained to deliver local anesthetic into the human body and are comfortable with dealing with the complications. By the way, the adverse reactions and complications associated with the local anesthetic we use are far more serious than those with Botox® and dermal fillers. After proper training, you will be equally comfortable with using Botox® as you are with local anesthetic. Having now trained hundreds of dental professionals and other healthcare providers in Botox® therapy, I can testify that dentists are the easiest to train, the most realistic and conservative with the treatment, and the best healthcare professionals to deal with any complications in the head and neck areas.
The other misconception that I run into routinely is that this takes a medical residency or months of training to learn how to perform Botox® and dermal filler therapy for cosmetic and clinical uses. In terms of training, dentists often think that the other healthcare providers, such as plastic surgeons and dermatologists, go through extensive training in their residencies on Botox® and dermal fillers. I have spoken to, have worked with, and have trained physicians and nurses in Botox® and dermal filler therapy. I have heard from numerous plastic surgeons, dermatologists and general physicians that unless the residency has a cosmetic component, these topics are not even covered. Indeed, many dermatologists and certainly most other physicians receive their training in Botox® and dermal fillers through one to two day courses. Nurses often receive on the job training. In many states, nurses and physicians assistants are allowed to deliver Botox®, dermal fillers, sclerotherapy, laser and chemical peels, and mesotherapy in independent practices without a physician present. Are we as dentists less qualified to deliver these procedures? I believe we are among the best qualified to do so. We need to seriously re-think these issues as a profession and stop letting our politics get in the way of common sense as it relates to esthetic facial procedures.
TRAINING IS THE KEY
Hands-on training is absolutely essential in learning how to provide these procedures and intertwining them with dental treatment plans. With proper training, dentists are usually more proficient than any of these other healthcare professions in providing these treatments to patients, both for dental and cosmetic needs. I have trained many dentists and other healthcare professionals and by far, dentists with their proficient knowledge of the facial anatomy and their experience with injections, are the best choice to provide these services to their patients and to realize the wonderful effects that Botox® treatment can have on the smile lines and facial esthetics.
Let’s broaden our horizons as a profession and use all of the tools available to us. Botox® therapy is a conservative, minimally invasive treatment that can expand our therapeutic options for the benefit of our patients and is a natural progression of where we are going in the dental industry. These procedures are easy to accomplish by general dentists with proper training. Patients are motivated to accept these therapies and would be excited at having this done by their dentist, the healthcare professional of choice to deliver these procedures. This is the perfect complement and the next step in complete cosmetic dentistry.
Dr. Louis Malcmacher is a practicing general and esthetic dentist in Bay Village, Ohio and an internationally known lecturer and author known for his comprehensive and entertaining style. An evaluator for Clinicians Reports (formerly Clinical Research Associates), Dr. Malcmacher has served as a spokesman for the Academy of General Dentistry and is a consultant to the Council on Dental Practice of the American Dental Association. You can contact him at 440 892-1810 or email firstname.lastname@example.org . You can also see his lecture schedule at www.commonsensedentistry.com where you can find information about Botox® and dermal filler training for dentists, teleconferences, audio cd’s and his free monthly e-newsletter.