April 2011
Volume 32, Issue 3

Botox Therapy in the Dental Practice

By Constantinos Laskarides, DMD, DDS, PharmD, FICD; Ronald Goldstein, DDS; and Louis Malcmacher, DDS, MAGD

Q:Should Botox therapy and filler enhancements be performed by dental professionals?

Dr. Laskarides

A: If the clinician possesses the adequate knowledge, training, and skills not only to offer the service but also to manage any possible resulting complications, then the clinician is entitled to incorporate this service into his or her practice. There should be only one standard of care offered to patients: the highest.

So the answer is “yes,” only if all of the above are secured. Currently, in dentistry, only specialty training in oral and maxillofacial surgery includes the necessary knowledge background and extensive training for performing facial cosmetics, including invasive and non-invasive procedures. Improving facial esthetics cannot be viewed as an isolated capacity to inject a medication, or filler, under the skin. Proper treatment planning calls for an experienced and knowledgeable provider who can assess, analyze, and offer a comprehensive solution to the patient’s concerns without limitations. Lack of proper training and small pitfalls may lead to considerable problems, compromised patient care, and subsequent liability. A small example is an aged patient who may be concerned with prominent horizontal dynamic rhytids of the forehead and presents to the clinician for chemodenervation with botulinum toxin. If this patient also has excessive upper eyelid “hooding” and/or brow ptosis and the clinician either fails to recognize or is unable to address this, then the injection of botulinum toxin not only may worsen the periorbital esthetics but also produce a functional problem affecting the patients’ peripheral vision.

I believe that, as with all other aspects of the dental profession, proper training and eligibility for certification by federal and state governing bodies (such as dental boards) should be offered by academic institutions, not commercial companies. I also believe that the general dental practitioner can and should be trained in non-invasive facial cosmetics, but the training has to be thorough. Being the course director of oral and maxillofacial surgery at Tufts University Dental School gave me the opportunity to introduce this subject, for the first time, in the students’ curriculum. This was a first step in the right direction that we hope to build upon.

Dr. Goldstein

A: Is the risk of a possible malpractice lawsuit worth the financial reward for your dental practice? Crossover healthcare is a current trend in the medical field today, but what concerns me is whether a dental professional taking a 2-day course matches the qualifications of a plastic surgeon or dermatologist who typically performs these procedures. I have no problem with a properly trained oral surgeon doing the procedures, but when a consumer is ready to select a professional for facial injections, why would he or she not seek out medical professionals who routinely perform these treatments and specialize in this field?

With potential lawsuits resulting from paralysis or necrosis, a dental practice would thereby be taking on greater permanent risks than with most any other normal dental procedures. An article from Summer 2008 at TDIC (The Dentists Insurance Company) highlights how one patient who suffered necrosis of the lip was able to settle a lawsuit against her general dentist for negligence in performing derma filler. The patient subsequently could not speak intelligibly unless she pinched her bottom lip and could no longer kiss. Her career as a professional trainer for a national healthcare group was over and her income dropped significantly. This dentist now has his name scattered across the Internet for the wrong reasons, and the first hit from a search of his name goes straight to the article about this case.

The concern I have is really not based on the actual injection itself. If you search Google for “botox failures” the very first link that comes up reports on eight celebrities who have come forward to speak about their Botox disaster. Seventy-two Google pages later they are still talking about Botox failures. Failure can mean not only necrosis, paralysis, or other nerve damage, but also esthetic failure when the patient is not happy with the esthetic results. Unfortunately, the way of the specialized dentist is now being watered down by medical esthetic hybrids.

So what is the motivation for competing with our medical colleagues? The most frequent answer I have received is that injecting Botox or fillers can be a new income source in a tight economy.

In 1976 I wrote the world’s first comprehensive textbook on esthetic dentistry that included the study of and treatment for total facial esthetics. Few people are more concerned than myself when it comes to total facial enhancement. But do we, as dentists, want to take on the added responsibility of possible negative outcomes from these facial injection treatments? Every dentist needs to make a choice for him or herself about the direction of their practice. So does the risk outweigh the rewards? For me, it does not.

Dr. Malcmacher

A: There is a huge misconception, and much confusion, that Botox and dermal filler therapy is not within the realm of dentists and dentistry. Nothing could be further from the truth. Currently, more than half the states in the United States and some provinces in Canada allow dentists to perform Botox and dermal filler procedures in all of the oral and maxillofacial areas for both cosmetic and therapeutic uses.

With plastic surgeons, dermatologists, internal medicine physicians, OB/GYNs, ophthamologists, podiatrists, nurses, physicians’ assistants, and medical estheticians (who may not even be medically trained) delivering Botox and dermal fillers 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 the 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 dentists use are far more serious than those associated with Botox and dermal fillers. After proper training, a dental technician will be equally comfortable with using Botox and dermal fillers as with local anesthetic. Having now trained thousands of dental professionals and other healthcare providers, including dentists, physicians, and nurses, in Botox and dermal filler therapy, I can testify that dentists are the easiest to train, the most realistic and conservative with the treatment, by far the most accomplished injectors, and among the best healthcare professionals when it comes to dealing with complications in the head and facial areas.

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 politics get in the way of common sense as it relates to our role as healthcare professionals who can deliver the best esthetic outcomes for our patients.

About the Authors

Constantinos Laskarides, DMD, DDS, PharmD, FICD
Assistant Professor, Course Director, Oral & Maxillofacial Surgery
Tufts University
Boston, Massachusetts

Ronald Goldstein, DDS
Private Practice
Atlanta, Georgia
Clinical Professor of Oral Rehabilitation
Georgia Health Sciences University—
School of Dentistry
Augusta, Georgia

Louis Malcmacher, DDS, MAGD
President of the American Academy of Facial Esthetics
General and Private Practice
Cleveland, Ohio

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