Question: Should dentists provide nontraditional services like Botox® and dermal fillers?
Dr. Kugel
“The times they are a-changin’.”
There was a time when the thought of dentists doing dermal fillers and/or Botox® (onabotulinumtoxinA) would have raised an eyebrow or two, but it seems that is no longer the case. Dentists and oral surgeons deal with the head and neck region more than most physicians.
In Massachusetts, where I practice, the Board of Registration in Dentistry frowned on dentists performing any of these procedures for many years, but recently their opinion changed. They now state that dentists who want to administer Botox and fillers must be board certified in oral and maxillofacial surgery or have completed a minimum of 8 hours of training in the administration of botulinum toxins and/or derma fillers that includes instruction in the anatomy of head and neck, neurophysiology, patient selection, pharmacologic effects and contraindications, management of complications, informed consent, and hands-on training on the administration of the agents. A continuing education provider approved by the American Dental Association (ADA) Continuing Education Recognition Program, the Academy of General Dentistry Program Approval for Continuing Education, or another nationally recognized and accredited entity approved by the dental board must offer the training.
I believe that the requirement for training is critical. It seems that today 20 states allow dentists to perform one or both of these procedures. With any medical or dental procedure, there are risks. The training and skill level of the doctor will limit these risks. It seems to me that a dentist with an esthetic eye is well suited to evaluate the symmetry and esthetics of the face and teeth. We are more knowledgeable than most other healthcare providers in the muscles of mastication and facial expression as well as facial esthetics.
Dentists getting involved in these procedures should think about the fact that many of the patients seeking these treatments are very demanding. They must be aware of the limitations and be able to communicate these to their patients to avoid any unreasonable expectations.
The ADA states that it supports dentists performing any procedure for which they are qualified by education, training, and experience and that is consistent with the laws of the state in which they are practicing. Those dentist who choose to perform these procedures need to check their state regulations.
Dr. Sesemann
My position on this question is shaped by my personal experience. Approximately 3 years ago, I decided to pursue training for cosmetic services such as Botox therapy and cosmetic fillers. I approached this training with an open mind to learn the techniques but also to decide whether it was something I wanted to add to our slate of services for the patients in my practice. One of the primary objectives was to prove to myself that as a dentist I had the knowledge and skill set that would allow me to perform these services at the highest level.
I attended lectures, demonstrations, and hands-on courses with a wide variety of professionals, including physicians of various specialties, nurses, and physician assistants. It quickly became apparent in lectures that my dental training and subsequent practice experience involving the facial musculature placed someone like myself in an enviable position within these groups. In effect, I already knew all of the anatomical content that some were learning for the first time.
That same level of comfort was apparent in subsequent demonstrations and hands-on training. It certainly should not come as a surprise that people who give injections all day have a proclivity with a syringe apparatus. My previous personal experience with injections included not only giving intraoral anesthetic, but also providing a variety of external injections such as supplementing mandibular block anesthesia with an infiltration of the superficial cervical nerve anterior to the sternocleidomastoid muscle. I also have experience giving a variety of external trigger point injections for myofacial pain syndrome and occlusal disorders. As with any technique, I found that performing this new skill appropriately was always contingent upon receiving proper training and exercising a responsible clinical acumen.
So, my personal experience has provided me undeniable proof that dentists can be natural providers of Botox and filler injections for our patients. I find it ironic that a propensity to deliver a certain service at the highest level may not be what ultimately determines what a state dental board allows practitioners within its jurisdiction to do. I hope that those decisions are ultimately made on the basis of who has the skill set, the knowledge, and the training to provide services such as Botox and dermal fillers, as opposed to which healthcare profession has the best political lobbying apparatus in place to “win” a decision for the group they represent in the name of commerce.
Dr. Goldstein
Although crossover healthcare is a current trend in the medical field today, I am inclined to disagree that a general dentist is as qualified to perform Botox therapy and filler enhancements as a trained medical professional who has a graduate medical degree and completed an internship and residency in a specialty. The exception would be an oral surgeon who has similiar training and has spent years studying facial muscles and surgical procedures and is keenly aware of the potential problems involved. Can a 2-day or even 2-week course give any individual enough confidence to practice Botox therapy and dermal fillers without the possibility of serious problems and even failure?
I agree with my friends Drs. Kugel and Sesemann that dentists have a keen esthetic eye, give more injections than our medical colleagues, and also have considerable knowledge of peri-oral facial musculature. In addition, many state boards have agreed that dentists are now licensed to perform the procedures in their states. So my concern is not whether dentists can and are doing the procedures; rather, is it worth the risk?
With potential lawsuits resulting from paralysis or necrosis, a dental practice could be ruined overnight. An article from the TDIC (The Dentists Insurance Company) newsletter Liability Lifeline from summer 2008 highlights how one patient who suffered necrosis of the lip was able to settle a lawsuit against her general dentist due to his negligence in administering derma filler. The patient subsequently could not speak unless she pinched her bottom lip to be understood 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 off a search of his name goes straight to the article about this case.
Another article reports problems from some users that the medication in Botox can spread from the area of the injection to other parts of the body. This can result in symptoms of botulism poisoning, including paralysis, difficulty swallowing, respiratory distress, and other issues. Even more of a concern for me is the patient who may get considerable peri-oral swelling, bruising, upper lid droop, uneven lip, or other problems. The answer I have heard the most is, “It is only temporary and it will return to normal in weeks or months.” However, these side effects could be especially troubling for patients overly concerned with their facial appearance, even if they are only temporary.
Dentists are specifically trained to give intraoral injections. In turn, plastic surgeons and dermatologists are trained in facial injections. Each professional uses his or her skills on such a routine basis that the margin for error is decreased. Unfortunately, the way of the dentist is now being watered down by medical–esthetic hybrids and motivated possibly by monetary gain.
It only takes one failure and one lawsuit for a practice to lose everything. Patients will interpret any failure as a reason to go elsewhere. Is it worth the headache to constantly worry about possible failure in a medical area of your practice in which you don’t have specialty training?
In addition, if you are a dental professional who relies moderately or heavily on referrals from plastic surgeons, dermatologists, and other cosmetic professionals, you will need to consider how they will see you as possible competition for business and no longer recommend you to potential patients.
The bottom line is that every dentist needs to make a choice for him or herself about the direction of the practice. Do the risks outweigh the rewards? For me, they do not.
About the Authors
Gerard Kugel, DMD, MS, PhD | Dr. Kugel is associate dean for research at Tufts University School of Dental Medicine in Boston, Massachusetts. He is also the editor-in-chief of Inside Dentistry.
Michael R. Sesemann, DDS | Dr. Sesemann is a dentist in private practice in Omaha, Nebraska. He is also clinical instructor at the Kois Center for Advanced Dental Education in Seattle, Washington.
Ronald Goldstein, DDS | Dr. Goldstein is a dentist in private practice in Atlanta, Georgia. He is also clinical professor of oral rehabilitation at Georgia Regents University College of Dental Medicine in Augusta, Georgia.
