Botox and dermal fillers have made a huge impact in the elective esthetic field. By far, these are the two fastest growing cosmetic treatments, especially over the last seven to eight years. The dollar amount spent on Botox and dermal fillers far exceeds the combined dollars spent for breast implants and liposuction. I hope through this article to show you that there is a definite place in the dental practice for both Botox and dermal fillers therapy and why dentists should be joining other health care practitioners who deliver these services. In truth, dentists are the primary health care practitioners who should be delivering these procedures to patients.
There is no question that this article will be controversial, but bear with me as you read through this and you will see a very strong case can be made for dentists’ involvement with Botox and dermal filler therapy. I have found now, after speaking to thousands of dentists through my lectures about these procedures, that we as a dental industry are pretty much ignorant of what these therapies even are, how they are delivered, what the science is behind them, and what they can accomplish for our patients. A little bit of knowledge provided by this article will go a long way in helping you understand about the clinical and practice management advantages to integrating these therapies into your office.
THE REAL FACIAL SPECIALISTS
The first question everybody asks is, “Don’t Botox and dermal fillers procedures belong in a specialist office, like a plastic surgeon or dermatologist office?” Dermatologists and plastic surgeons were the first healthcare providers to train and integrate these therapies into their offices but that does not make these “specialty” procedures by any means.
At this point in time, these procedures are delivered to patients by other physicians including OB/GYN’s, ophthalmologists, gastroenterologists, internists, registered nurses, physicians’ assistants, medical estheticians (who may or may not be medical personnel), and even podiatrists! As you will soon see, I would submit that dentists are the true specialists in the area of the face, much more so than these other healthcare personnel.
In many times states, a registered nurse or physicians’ assistants can have an independent practice outside of the physicians’ office and perform Botox, dermal fillers, chemical and laser microdermal abrasion, sclerotherapy, and mesotherapy. Even within dermatology and plastic surgery offices, registered nurses and physicians’ assistants are the primary providers of Botox and dermal fillers. Many nurses that I have spoken to have told me that their training was completely on the job with absolutely no additional training in facial anatomy, physiology, pharmacology of the products, and adverse affects. They just learned where to place these materials by watching and learning.
Here is where I want to make a strong point. We, as dentists, really have to start standing up for ourselves and realize how advanced our training has been in the oral and maxillofacial areas (that means the face from chin to forehead) than just about any other healthcare professional who is now allowed to deliver Botox and dermal fillers to patients. Dentists often challenge me that these procedures are best left to physicians. The question that you really have to ask yourself is, “Why?” An ophthalmologist, general plastic surgeon, dermatologist, OB/GYN, most other MD’s, nurses, and physician assistants do not even come close to knowing the facial, oral and perioral areas compared to a general dentist. Dentists are much more familiar with how to take care of complications in these facial areas than these healthcare providers. Yet, all of these healthcare providers are allowed to deliver Botox and dermal fillers and in some states dentists are excluded from doing so. Dentists do many more invasive procedures in the facial areas than all of these physicians and personnel combined. The facial, peri-oral, and oral areas are where we live every single day!
I completely understand that the thought of Botox and dermal fillers is foreign to our dental mindset simply because we have never been involved in these areas before. You may also remember there was a time when implants were foreign to dentistry, with many dentists saying we should not get involved because that would change our mindset of trying to save teeth. When teeth whitening was first introduced into the dental market, many dentists called it malpractice. It is time to really start learning about how Botox and dermal fillers can help us in dentistry.
THE BOTOX PRIMER
Botox is a trade name for botulinum toxin, which comes in the form of a purified protein. The mechanism of action for Botox is really quite simple. Botox is injected into the facial muscles but really doesn’t affect the muscle at all. Botulinum toxin affects and blocks the transmitters between the motor nerves that innervate the muscle. There is no loss of sensory feeling in the muscles. Once the motor nerve endings are interrupted, the muscle cannot contract. When that muscle does not contract, the dynamic motion that causes wrinkles in the skin will stop. The skin then starts to smooth out, and in approximately three to ten days after treatment, the skin above those muscles becomes nice and smooth. The effects of Botox last for approximately three to four months, at which time the patient needs retreatment.
The areas that Botox is commonly used for smoothing of facial wrinkles are the forehead, between the eyes (glabellar region), and around the corners of the eyes (crow’s feet) (Figures 1&2) and around the lips. Botox has important clinical uses as an adjunct in TMJ and bruxism cases, and for patients with chronic TMJ and facial pain. Botox is also used to complement esthetic dentistry cases, as a minimally invasive alternative to surgically treating high lip line cases, denture patients who have trouble adjusting to new dentures, lip augmentation, and has uses in orthodontic cases where retraining of the facial muscles is necessary. No other healthcare provider has the capability to help patients in so many areas as do dentists.
THE DERMAL FILLER PRIMER
Dermal fillers will volumize creases and folds in the face in areas that have lost fat and collagen as we age. After age 30, we all lose approximately 1% of hyaluronic acid from our bodies. Hyaluronic acid is the natural filler substance in your body. The face starts to lack volume and appears aged with deeper nasolabial folds, unaesthetic marionette lines, a deeper mentalis fold, the lips start to thin, and turning down the corners of the lips (Figure 3). Hyaluronic acid fillers such as Restylane and Juvederm are then injected extraorally right underneath these folds to replace the volume lost which creates a younger look in the face (Figure 4). Dermal fillers can be used for high lip line cases, asymmetrical lips around the mouth, lip augmentation, and completing cosmetic dentistry cases by creating a beautiful, young-looking frame around the teeth. The effect of dermal fillers typically last anywhere from 6 to 12 months at which point the procedure needs to be repeated. Both Botox and dermal fillers are procedures that take anywhere from 5 to 15 minutes.
There is one huge advantage dentists have in delivering dermal fillers over any other healthcare professional. Most physicians and nurses use topical anesthetics and ice on the skin to numb the patient. Some actually learn how to give dental anesthesia but very few are proficient at it. As you may imagine, this will be a painful procedure when done this way. Indeed, this is the reason that many patients prefer dentists to deliver dermal fillers.
The interesting thing here is that most dentists inject in the same areas where Botox and dermal fillers are injected for cosmetic results. The only difference is that you inject intraorally into these facial structures while Botox and dermal fillers injections are extraoral injections. Another reason that dentists are the best professionals to deliver these applications is also because we are the best injectors around. We inject anesthetic for a living and we know how to make these injections comfortable, quick, and relatively painless for our patients. The dentists I have trained for Botox and dermal fillers all report that their patients compare us to the other healthcare professionals they have gone to before for these procedures and by far, the dentists injections are quicker and much more comfortable.
WHAT ABOUT ADVERSE REACTIONS?
People always ask me about adverse reactions to Botox and dermal fillers. The long-termed safety of Botox has become very well established clinically, with millions of injections delivered every single year. Botox treatments are the most commonly performed cosmetic procedures in the United States and would not be so if there were common adverse reactions. The most common dermal fillers used are made of hyaluronic acid which, as we mentioned, are naturally occurring substances in the body. When the effects of Botox and dermal fillers are gone, they are gone completely with no residue or after effects present.
I always tell dentists who are worried about adverse reactions to pick up the pharmacology sheet that comes with your local anesthetic. You will find far more adverse reactions that can go wrong with the use of common local anesthetics that can have significant effects on the cardiovascular system, nervous system and muscular system. That sheet describes far worse reactions than with Botox and dermal fillers, yet we are comfortable using these every single day. The reason is because we are knowledgeable about the use of local anesthetic, we have studied what it can and cannot do, and we have been trained in how to deal with any complications. The same will be true once you are properly trained with Botox and dermal fillers.
YOU CAN TEACH AN OLD DOG NEW TRICKS
This brings me seamlessly to the topic of training. Every dentist that has been trained in Botox and dermal fillers completely understands why we as dentists should be performing these procedures. It is estimated that approximately 10% of dentists have been trained in these procedures. Training is absolutely essential, just as it is with anything that is new to you. I have personally trained hundreds of dentists in Botox and dermal filler therapy and it is quite amazing to see dentists go through a wonderful transformation through the course. You see, you the dentist already know the facial anatomy – it’s somewhere in your brain from dental school and we just have to bring it back to the surface. You already know how to give an injection and this is just a different kind of injection to learn. You already understand the physiology, skeletal structures, vascular and nervous system of the face, and overall facial esthetics.
Do you think for a moment that other healthcare professionals know or are concerned about the proper ratios of lips to teeth, the smile considerations when the patients go into a partial or a full smile, proper phonetics, and how the teeth relate to the soft tissue surrounding the mouth? I have found just a few plastic surgeons and dermatologists that have a very cursory understanding of this, but don’t really give it much thought at all.
The face and certainly the lower face is where we live every single day and once you are properly trained in Botox and dermal filler therapy, you will be able to complete a much better cosmetic and dental result for your patients by starting to start out of the mouth a little bit and not limiting yourself to just being a teeth doctor.
There are general medical education companies that will teach courses on Botox and dermal fillers. Generally, some of this course is wasted on dentists as there is a definite lack of dental knowledge as to how these procedures can be used in conjunction with other dental procedures. There are other procedures that are done with Botox and dermal fillers that are not used around the face and would be completely outside of the dentist’s realm. Training for the dentist is significantly different than training for other healthcare professionals as our procedures are limited to the face and the training must include how to best use these materials for the clinical dental uses mentioned above in addition to smoothing of facial wrinkles and volumizing facial folds.
WILL MY MALPRACTICE INSURANCE COVER THESE PROCEDURES?
Malpractice issues are rare for Botox and dermal filler cases. That being stated, I have always been a strong advocate that professionals should have malpractice insurance that covers all the procedures they perform. Dental liability insurance companies are not now set up to cover dentists for Botox and dermal filler procedures. This means that your malpractice insurance carrier will not cover you for these procedures.
So many dentists contact me and tell me that they heard from their malpractice insurance agent that dentists are prevented from doing botox and dermal fillers in their state when this is simply untrue. While most insurance agents are well intentioned, they are afraid of losing your business. I have proven many an insurance agent and insurance executives wrong on this issue. It is what the state dental board tells you that is relevant, not your insurance agent.
Here is the great news for you and your insurance agent – there are third party add-on malpractice liability insurance carriers that will cover dentists who have been properly trained for these procedures and we work with a few through our training courses. These policies will be in addition to the malpractice insurance you already have.
STATE DENTAL BOARDS
Most dentists are surprised to learn that there are many states where general dentists are completely allowed to perform both Botox and dermal fillers in the oral and maxillofacial areas from chin to top of the forehead. There are some states that may allow one and not the other. There are states where dentists are not allowed to perform these therapies at all. There is no question that the tide is certainly turning for this to be accepted nationwide with more state dental boards allowing these procedures and it is happening rapidly. Certainly, it is certainly appropriate for dentists to use Botox and dermal fillers for dental uses within the scope of dentistry as defined by your state practice act.
It is high time that our state dental associations (which represent dentists) begin advocating to the state dental boards (who work for the public) and to their state legislatures for dentists to begin doing these procedures for those states not on board yet. I have consulted with many state dental boards about these issues. The more state dental board members become educated about what these procedures are and how dentists are the best healthcare professionals to provide these services, the faster the shift will be to allow dentists to do these procedures in those states.
State dental boards are there to protect the public. Does it make any sense at all when those most qualified to perform Botox and dermal fillers (dentists) are excluded from doing so? When nurses or MD’s with minimal or no training are allowed to do these procedures, how does that serve the public interest? It is just inconceivable that a nurse, physician, or physicians’ assistant who may not even have training can perform these procedures while a dentist, who knows more about the face than any of these other professionals, cannot do so. I have many friends who are on state dental boards and they work hard and with honor in fulfilling their duties to the citizens of their states. We need to support them in their efforts to do so.
POST OP INSTRUCTIONS
Instead of the naysayers in dentistry who always doubt our abilities as healthcare professionals, it is time to stand up and realize how well trained, clinically proficient and knowledgeable dentists truly are in all of the oral and maxillofacial areas. We need to realize that we have valuable contributions to make in facial esthetics and it is time to get on board.
Dr. Louis Malcmacher is a practicing general dentist in Bay Village, Ohio and an internationally known lecturer, author, and dental consultant 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 AGD and is a consultant to the Council on Dental Practice of the American Dental Association. He works closely with dental manufacturers as a clinical researcher in developing new products and techniques. For close to three decades, Dr. Malcmacher has inspired his audiences and consulting clients to truly enjoy doing dentistry by providing the knowledge necessary for excellent clinical and practice management. His group dental practice has maintained a 45% overhead since 1988. 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 his botulinum toxin and dermal filler training, building the best dental team ever, big case acceptance success! and sign up for his affordable monthly consulting programs, teleconferences, audio cd’s and free monthly e-newsletter.