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Botox and dermal fillers are well known for their esthetic results in terms of smoothing wrinkles in the skin and replacing the lost volume in the face, especially the oral and perioral areas. Botox has been used for this purpose for over 21 years and is the most commonly performed minimally invasive cosmetic procedure in North America.

Botox (Botulinum Toxin) is a neurotoxin in the form of purified protein. The misconception is that it paralyzes the muscles. The truth is that when it is injected into facial muscles, it doesn’t really affect the muscle at all. It works by blocking the transmitters between the motor nerves that innervate the muscle.

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Dermal Filler (ie; Juvaderm; Restylane), is a soft tissue filler (most popular type is hyaluronic acid) injected into the skin to help fill in facial wrinkles, lines and creases, restoring a smoother appearance. They can also be used as “volumizers” to plump areas of lost volume. Most of these wrinkle fillers are temporary because they are eventually absorbed by the body.

The use of Botox and dermal fillers is becoming one of the fastest growing areas of dentistry. Approximately 7-8% of dentists (and growing) in North America are now providing Botox treatment for cosmetic treatment, but other innovative uses are being found in dentistry.  Over 35 states in the U.S. and most Canadian provinces allow Botox and dermal fillers for therapeutic purposes for the practice of dentistry as defined by the dental practice act. Other states and state dental associations are lobbying to allow dentists to begin performing these procedures. The laws of some states are vague (not specific on whether it is allowed or not; ie; “Board of dentistry does not currently have any policies regulating the use of Botox or dermal fillers by dentists…., etc. ). You will need to check with your state dental board laws specifically on their website or here.

Most dentists are not aware of the substantial benefits that Botox has as an adjunctive therapy in dental and cosmetic treatment but it is being used to help tackle some of the most difficult clinical situations dental practitioners encounter. As dental professionals, it is our legal and ethical duty to tell patients about all relevant options available for their dental treatment. In this day and age, dentists can become trained in the use of these materials, as they are well-established and viable treatment options as adjunctive therapy and to complement aesthetic dental cases.

There is a huge misconception and confusion that Botox Therapy is not within the realm of dentist or dentistry. Plastic surgeons, dermatologists, internal medicine physicians, OB-Gyns, ophthalmologists, podiatrists, nurses, physician assistants and medical estheticians (who may not even be medically trained) deliver Botox to patients in the oral and maxillofacial areas. It is well past due that dentists are recognized as being “real doctors” and are part of the “medical arena” the same as physicians. Dentists are more than teeth doctors. It is certainly time to recognize that dentists are much more proficient in injections than any of these healthcare providers. Besides, dentists are the specialists in the oral and maxillofacial areas and 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. Every time dentists inject local anesthetic into a patient, they are delivering a medicinal agent into the body that has real possible systemic complications. The only difference is that dentists have learned and been trained to deliver local anesthetic into the human body and are comfortable with dealing with any possible complications. By the way, the adverse reactions and complications associated with local anesthetics (ie; cardiovascular system, nervous system and muscular system) dentists use are far more serious than those with Botox and dermal fillers . Dentists are the best healthcare professionals to deal with any complications in the head and neck areas.

Training for the Use of Botox and Dermal Fillers

Numerous plastic surgeons, dermatologists and general surgeons say that unless their residency has a cosmetic component, the topics of fillers and injectables are not even covered. Dermatologists and most other physicians receive training in Botox and fillers  through 1-2 day courses. Nurses receive on the job training. In most states, nurses and physician assistants are allowed to deliver Botox, fillers and other therapies/procedures in independent practices without a physician present. “With proper Botox education, dentists are usually more proficient than any of these other healthcare professionals in providing these treatments to patients both for dental treatment and cosmetic needs”, according to Dr. Louis Malcmacher, a dentist and educator for the American Academy of Facial Esthetics (AAFE), because of dentists’ proficient knowledge of facial anatomy and their experience with injections. Dentists routinely inject in the same areas but intraorally and Botox/Dermal fillers are injected extraorally.

Training for dentists is significantly different. Dental procedures are limited to the face and training must include how to best use these materials for clinical and dental uses in addition to the smoothing of facial wrinkles and volumizing facial folds. Botox education is a Botox training course specifically for dentists. Training includes hands-on instruction using live patients and a thorough understanding of the products, anatomy of where the products are placed into and how they affect the esthetics of the face. When choosing a dentist for Botox and dermal fillers, it is important to choose one that has proper Botox certification. Botox certification should entail at least 16 hours of live hands-on patient training, which upon completion the doctor will presented with the proper certification.

The faculty of the American Academy of Facial Esthetics  has trained thousands of dental professionals to become proficient in the use of facial injectables in dentistry and continue to work with and educate state dental boards in this area of dentistry. Now that dentists understand Botox and dermal fillers in dentistry for therapeutic and aesthetic cases and have become proficient in their use, we can offer them in addition to our current treatment options. The outcomes of using these materials will rival and many times surpass many dental therapy outcomes now available for both routine and challenging dental treatment cases.

Therapeutic uses for Botox include:

  • TMD Cases (116 million Americans suffered from jaw-related pain in 2013)

  • Bruxism/Clenching Cases
  • Facial Pain Cases (including trigger points)
  • Treatment of Angular Cheilitis
  • Gummy Smiles
  • Orthodontic Relapse and Depressed Orthodontic Appearance
  • Reducing Muscle Hyperactivity for Retention of Removable Prosthodontics
  • Oromandibular Dystonia
  • Masserteric Hypertrophy
  • Trigeminal Neuralgia

Dermal fillers are used in the nasolabial folds, lips, mentalis fold, labiomental folds and intraorally are used in gummy smiles, establishing aesthetic dental lip lines and smile lines in aesthetic dentistry cases as an alternative to a gingivectomy, crown lengthening and veneers. Can also be used to eliminated “black triangles” between teeth after periodontal and implant treatment that did not preserve the papilla. Re-establishing lip volume for proper phonetics (in addition or as opposed to tooth lengthening with fixed or removable prosthodontics), and adding lip and perioral volume around the mouth for retention of removable dentures is another use.

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Image Credit (gummy smile): dermaskin.co.uk

In comparison to the more invasive and/or aggressive treatment options that are traditionally used in dentistry to correct the above mentioned conditions/issues, (ie: surgery), Botox and fillers results will be close to immediate, usually achieved in 1 appointment and there is no removal of any tooth structure (in “black triangle” correction”). The advantages of traditional treatments include: longer lasting results and aesthetics but the disadvantages are a higher cost initially, several appointments needed, possible complications including sensitivity with the possibility of other treatments needed later on and necessary re-treatment in 10-15 years as gum recession occurs (“black triangle” correction). The disadvantage of Botox and fillers is re-treatment will be needed 2-3x per yr (fillers last 6-12 months) and the costs associated with that treatment (“black triangle” correction). With Botox and dermal fillers, the patient will experience short visits, approximately 5-20 minutes but these treatments will need to be repeated over time. Both traditional treatment and Botox/dermal fillers are great options. It is ultimately the patient’s decision. It just significantly expands the treatment choices we now have in dentistry.

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Image Credit (black triangles): jcdr.net

Costs/Fees

Costs of Botox and dermal fillers in the dental office will vary. Sometimes the fees are associated with complete dental treatment meaning some offices package facial services with the dental services that are going to be done in conjunction. This is unique to that specific dental office. Costs can also be done according to how much of the actual product is being used, different areas of the face treated or an overall treatment fee involving the facial aesthetic case including a smile makeover. Another fee schedule involves Botox and dermal fillers fees alone. This generally depends on the number of areas used, how much material and if any soft tissue averaging $600-$3,000 plus any other dental treatment (ie; 5-20 minutes and product cost $50-$500).

Once upon a time, teeth whitening, dental implants and dental veneers used to be considered “extreme and crazy” treatments. The goal and priority in dentistry has always been physical health and function and patient’s feelings of well-being and self-esteem were considered outside the realm of dentistry. But now we know that all of those things go hand-in-hand.  Function and aesthetics are partners in optimal health. According to Dr. Malcmacher, “Botox therapy is a conservative, minimally invasive treatment that can expand therapy options for the benefit of the patient and is a natural progression of where we are going in the dental industry”. “It is a perfect complement and the next step in complete cosmetic dentistry”. Dentist are commonly associated with teeth but they are also experts in the head, face and neck. They already understand the physiology, skeletal structure, and vascular and nervous systems of the face and overall facial aesthetics. Dentists know and are concerned with proper ratios of the lips to teeth, smile considerations when the patient goes into partial or full smile, proper phonetics and how the teeth relate to the soft tissue surrounding the mouth. This is not given much thought by most other healthcare professionals.

The use of Botox and dermal fillers for soft and hard tissue dental therapy aesthetic cases is as much a dental treatment as any of the traditional options. Studies show that 73% of patients treated for TMJ with Botox saw immediate improvement. Once trained on these procedures and thoroughly understanding the anatomy, physiology, pharmacology, dealing with adverse reactions, and everything else there is to know about them, then you will find that the many therapeutic uses in dentistry for both functional and dental aesthetic purposes are just as effective or even more effective than traditional treatments and definitely have a place in dentistry. Remember: Dentist are the only healthcare professionals that can practice total facial aesthetics because they are the only ones who can actually treat teeth.

*Disclaimer: The information in this post is for informational purposes only and should not be taken as medical/dental advice. Consult your own licensed professional for advice.