This article they will stir up some controversy, but if you stick with me you will understand that there are very good reasons for dentists in particular to offer Botox and dermal filler therapy. I have spoken to thousands of dentists over the years and found that the dental industry as a whole knows little about these therapies, how they work, how to administer them, and what benefits they can offer patients. In this article, I hope to offer a little knowledge to help you understand the advantages of offering these therapies.
Nearly everyone I talked to asked me, “Shouldn’t Botox and dermal fillers be restricted to plastic surgeons, dermatologists, or other facial specialists?” Well it is true that Botox and dermal filler therapies were originally offered by dermatologists and plastic surgeons, this does not mean that these therapies should necessarily be restricted to these disciplines.
In the years since these procedures were developed, they have come to be offered by many other physicians, including ophthalmologists, internists, OB/GYN’s, gastroenterologists, registered nurses, physicians assistants, and even medical aestheticians (who may not even be medically trained). I would argue that dentists, because they work in the area of the face every day, are far more qualified than just about any of these other professionals.
Many states allow registered nurses and physicians assistants to run their own independent practices outside of physicians’ offices. They may offer procedures such as Botox, dermal fillers, chemical and laser micro-dermabrasion, and even sclerotherapy and medicine therapy. Even in a doctor’s office, such as a dermatologists or plastic surgeons office, registered nurses and physicians assistants are the ones who primarily administer Botox and dermal fillers. Many nurses learn how to administer these products on the job. Most of them undergo no training in the anatomy and physiology of the face, product pharmacology, or how to prevent and manage adverse reactions. They simply learn how to inject these products by watching.
Here is the basis of my argument: Dental training involves much more than just the teeth. As dentists, we undergo extensive training in all oral and maxillofacial areas. What this means is, we know just about all there is to know about everything from the chin to the forehead. It’s often been suggested that these products should only be used by physicians. To which I respond, “Why?” Few other doctors are anywhere near as knowledgeable about the face as a dentist. They are certainly less familiar with potential complications that can affect the face and how to treat them than these other professionals. Despite this, some states allow these other professionals to offer these procedures, while excluding dentists from providing them. Does this really make sense? After all, dentists all but live the oral, peri-oral and facial areas every day.
While it’s completely understandable that the idea of offering Botox and dermal fillers is difficult for dentists to wrap their mind around, it’s important to understand that this is simply because these procedures are new, especially in the world of dentistry. One must remember that many dentists felt the same way about implants, because it was thought that we would lose focus on trying to preserve teeth. Teeth whitening was met with similar disdain, many dentists going so far as to call it malpractice. It is time to do now is the time to start exploring how Botox and dermal fillers can be a boon to the dental industry.
Botox is the brand name of botulinum toxin, which is sold as a purified protein. Botox’s mechanism of action is not at all complicated. When injected into tiny facial muscles, the muscles themselves are not affected at all. Botox blocks communication between motor nerves and the muscle, so that the muscles are unable to contract. When the treated muscle is unable to contract, the movement that causes the skin to wrinkle will stop. Over a course of up to 10 days after treatment the skin above the treated area smooths out. The effects of treatment last about 3 to 4 months, after which repeated treatment will be needed.
Botox is most often used to smooth out wrinkles in the forehead, the area between the eyes also known as the glabellar region, around the outside corners of the eyes, what some people term crow’s feet, the area around the lips, and the area between the lips and nose. Use of Botox goes well beyond the aesthetic, however. Botox can be used as an adjunct treatment for both TMJ and bruxism, and for people with chronic pain in the jaw or face. Botox can also be used in conjunction with aesthetic dentistry, as an alternative to surgery for treating high lip lines, and lip augmentation, to aid patients with new dentures who have trouble adjusting, and in orthodontic cases that require retraining of facial muscles. No other healthcare provider is able to use Botox in as many different ways as dentists.
DERMAL FILLERS 101
Dermal fillers work by filling out creases and folds in the skin of the face were age has caused a natural decrease in fat and collagen. After we had 30, the amount of hyaluronic acid in our bodies decreases by about 1%. Hyaluronic acid is a substance produced by the body that acts as a natural filler. As the amount of the substance in the body decreases, facial volume decreases and wrinkles tend to deepen. This is most apparent around the lips, between the lips and the nose, and under the mouth. This results in the lips growing thin in the corners of the lips turning down, causing the appearance of a perpetual scowl. Hyaluronic acid fillers like Restylane or Juvederm are administered around the mouth directly underneath these creases to essentially fill out the skin for a younger appearance. Dermal fillers are not limited to use as a nonsurgical facelift, but can be used to treat high lip lines, and even lips, lip augmentation, and even complementing cosmetic dentistry to create a younger -looking frame for the teeth. The effects of dermal fillers generally last 6 to 12 months before needing to be repeated both Botox and dermal fillers take no more than 15 minutes to perform.
Besides extensive knowledge in the maxillofacial area, dentists have another major advantage over other healthcare professionals when it comes to administering dermal fillers. Most other healthcare providers use topical anesthetics to non-the area to be treated. If you do learn how to administer local anesthesia, though very few have mastered the process. As I’m sure you can imagine, the procedure is more painful this way. For this reason, many patients who have had the procedure done by both dentists and another professional will tell you the process is much easier when done by a dentist.
One thing to note is that dentists frequently already inject substances into the same areas that Botox and dermal fillers are used. The only difference is that traditional dental medications are injected intraorally into these areas, while Botox and dermal fillers are injected extra-orally. Another reason that dentists are most qualified to offer these products is because they are so proficient at administering injections. Dentist inject anesthetic just about every day and have mastered the art of making administering injections quickly and with little pain. Many dentists report that patients compare them to other healthcare professionals say the injections done by dentists are faster and more comfortable than those done by other healthcare professionals.
Many people are concerned about potential adverse reactions. Botox has a long record of clinical safety and is injected millions of times a year. Botox treatments would not be nearly as popular if adverse reactions were common. Most dermal fillers are made from hyaluronic acid which is a substance that is naturally produced in the body. After the effects of Botox and dermal fillers have dissipated, they are gone, and there is no residue or long-term effects. The advantage of this is that less than desirable results also disappear within a few months.
Dentists who are concerned about adverse reactions should read the insert packaged in any local anesthetic. Those local anesthetics carry far more potential for adverse reactions and more severe adverse reactions that Botox or dermal fillers. Adverse reactions from local anesthetics can effect cardiovascular, nervous, and muscular systems. These reactions are much worse than any that can occur with Botox or dermal fillers, yet we inject those every day. The reason we are so comfortable with local anesthetic is because we know what it can and cannot do. What’s more, we know how to minimize and address any complications that may arise. You will find the same to be true once you are familiar with Botox and dermal fillers.
LEARNING NEW TRICKS
So how do you become as comfortable with Botox and dermal fillers as you are with local anesthetic? The short answer is, the same way you became so comfortable with local anesthetic, through training. Every dentist trained in the use of Botox and dermal fillers understands why Dennis should be offering these procedures. It is estimated that approximately 10% of dentists have been trained. Just as with anything else that is new, training is essential. I have hundreds of dentists and the transformation is amazing. Dentists know all there is to know about facial anatomy; you really just need a refresher. You already know how to give injections; this is just a little different. You are already familiar with the physiology and structures of the face, as well as overall facial aesthetics.
The fact of the matter is other healthcare professionals are either unconcerned with, or are familiar with, how the lips, teeth, and other structures surrounding the mouth work together to create a beautiful smile and proper phonetics. Even most plastic surgeons and dermatologists have little more than a basic understanding of these things.
The face, most particularly the lower part of the face, is where the dentist spends many hours every day. With proper training, you can care for your patients much better by extending your practice out of the mouth rather than limiting yourself to just caring for teeth.
A number of medical education companies offer courses on Botox and dermal fillers. However, much of the content in these courses is wasted on dentists. Part of the reason for this is because these courses are lacking in information on how these products can be used to complement dental procedures. Another part is because these courses provide a great deal of information on procedures not involving the face, which is outside the realm of dentistry. Training that is geared specifically for dentists is significantly different than what is offered other healthcare professionals because it focuses solely on procedures performed in the facial area. They also include specific training on how to use the materials for dental uses as well as esthetic.
The fact is, malpractice cases involving Botox and dermal fillers are rare. However, it is very important that any healthcare professional have malpractice insurance that covers any kind of procedure they may perform. Currently, most dental liability insurance companies do not cover dentists for these types of procedures. This means there is a very good chance that your current malpractice insurance policy will not cover them, and you may need additional insurance.
Many dentists have been told by their malpractice insurance agents that their state does not allow dentists to administer Botox or dermal fillers. While a few states do not allow dentists to administer Botox or dermal fillers for cosmetic purposes, every state allows dentists to administer the products for therapeutic purposes, in most states do allow dentists to use the products for cosmetic purposes. I do believe that most of these agents mean well, they are simply afraid of losing your business. What is important is not what your agent tells you, but what the dental board in your state tells you.
I have good news for both you and your insurance company. You can’t get add-on malpractice liability insurance from third-party carriers once you have been properly trained. Even better, we work with a few of these agencies. These policies do not replace your existing coverage, but adds to it.
STATE DENTAL BOARDS
Many dentists are pleasantly surprised when they find out that many states allow general dentists to administer injections of both Botox and dermal fillers in the maxillofacial areas. A few states allow Botox but not dermal fillers, while a few allow dermal fillers but not Botox. There are also a few states where dentists are not allowed to offer these products at all. However, there is no doubt that things are changing and state dental boards are increasingly allowing the procedures. There is no doubt as to the appropriateness of dentists offering Botox and dermal fillers for dental purposes as the scope of dentistry is defined by your state.
The time is now for state dental associations, whose job it is to represent dentists, to start urging state dental boards, whose job it is to represent the public and state legislatures to allow dentists to offer these procedures the states where they are currently disallowed. As more dental board members learn more about these procedures, how they work, what they can do, and why dentists are by far the best qualified to offer these services, those states will gradually shift to include these procedures within the scope of dentistry.
The purpose of state dental boards is to protect patients and the public. However, it makes absolutely no sense to not allow dentists, who are the most qualified to offer Botox and dermal fillers, to do so. If nurses and physicians with minimal training, and almost none of the training given to dentists, should be allowed to perform these procedures, then dentists should be allowed to do so as well. Those who serve on state dental boards work hard and honorably to fulfill their responsibilities and protect residents of their respective states. As dentists, we need to support them in these efforts. To this end, it is important that these board members have all of the relevant information when making these decisions.
POST OP INSTRUCTIONS
The first step in addressing the naysayers who doubt the abilities of dentists as healthcare professionals is to understand just how highly trained, clinically effective, and experience you as a dentist are in all areas of the face, not just the teeth. As soon as you understand just how much of a contribution you can make in facial esthetics, and how much benefit you can offer your patients, you will be ready to undergo training and start offering the procedures yourself.
Dr. Katz is the President and founder of Dentox, a premier teaching facility for dental Botox and dermal fillers and has co-invented most indications for dental uses of Botox. Dr. Katz has injected and supervised injections on more patients than any other educator in this field. It is with this extensive experience that he has created protocols for dental esthetics of dermal fillers for many US cosmeceutical companies.
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