PERSPECTIVES

The Dentist, Botox, and Injectable Fillers

If not us, who? If not now, when?

It is my educated and experienced opinion that no

health care professional is better trained or positioned
than the dentist to address the patients orofacial
esthetic concerns. The heightened interest in perioral
esthetics in recent years is multifaceted. The fact that
the facial appearance plays a role in the quality of ones
life has been conrmed in behavioral, scientic
outcomes-based research.1,2 Historically, the ideal
occlusion dictated natures intended ideal form.
The ideal has shifted. The ideal has now become the
pursuit of optimal esthetics while maintaining the
fundamental tenants of stable dental structure and
functional occlusion.3 Optimal esthetics is consistent
with oral health and maintenance, and to some patients
is paramount.4 One of the earliest and most insightful
clinical, esthetic scholars was Dr. Ronald Goldstein. In
his book Change Your Smile, he emphasized the
imperative of looking at the face as an esthetic unit, not
compartmentalizing its components.5 Advances in

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pharmacology and the development of eective

biocompatible augmentation materials now allow
modication of the perioral structures in a safe,
predictable fashion. Patients expect their dentist, not
their physician, to oer a treatment plan that provides
not only restorative dental health, but one that also
includes a comprehensive approach to optimal
appearance. The dentist is the treatment coordinator.6
It is not a question of whether the dentist should be
aware of perioral esthetics; the dentist should be the
key professional component.
The contemporaneous question that mandates this
dialectic discourse is: how active should the dentist be
in the actual treatment of the perioral structures in the
pursuit of the optimal smile and facial form? Any
reasonable, sustainable conclusion requires objective
analysis. What parameters should determine whether
the dentist can adeptly perform tasks associated with
esthetic extraoral facial procedures hereto for relegated
to the physician or their delegate? In diagnostic and
therapeutic health care, the universal requisite for
qualication is whether the provider can satisfy the
standard of care. In determining tort, ethical, or
technical performance, the professional must achieve
certain minimal outcomes. The capacity to do so is
predicated upon education, training, and experience.
The training experience for most physicians providing
adjunctive esthetic services like neurotoxic therapy
(Botox, Dysport, Xeomin) and injectable llers is
nonexistent at the medical school level and has only
recently become available in select residency programs.
In the past, the typical medical provider viewed a DVD
and may or may not have received facilitated hands-on
instruction from a product representative or
independent trainer. Most medical practice acts dene
the practice of medicine in a way that allows broad
discretion on the part of the practitioner. Physicians
determine their level of adequate training. Indeed, the
statutory authority is there for physicians to perform
the task with very little, if any, scrutiny of their
qualication. In medical undergraduate education,

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there is no core curriculum or even a tangential

experience directed toward understanding oral facial
form, much less the parameters for an esthetic smile.
On the other hand, with dentistry: raison dtre. The
dental education experience in gross anatomy
embryology, neurophysiology, mastication, and
occlusion provides the essential knowledge base
necessary to best assess and treat not only the dental
alveolar structures, but indeed the adjacent anatomy
(soft tissue matrix) as well. How can we expect our
medical colleagues to understand proper tooth/lip
relationship or the eect of anterior crown contours on
lip support when the vast majority cannot even number
the teeth? Likewise, they have essentially no
understanding of the eect of vertical dimension on lip
morphology and competence. In some states, the
majority of these adjunctive services are being
performed by nurses. Nurses training generally consists
on-the-job instruction over an unspecied period by
the primary care physician. Nurses receive no formal
education in oral facial anesthesia, much less perioral
esthetics. Some of the most popular postgraduate
training opportunities for physicians in the United
States are being staed and instructed by nurses. When
it comes to determining proper standards of training
directed toward the art and science of optimal perioral
esthetics, facial form, and function, the evidence is
conclusive: the dentist is better trained. This basic
educational experience does not even take into account
the technical skill and ecacy. From the rst year of
dental school in morphology, hand/eye coordination
and dexterity are instructed and critically evaluated.
There is no skill assessment or practical experience in
dexterity for the vast majority of physicians and even
less for nurses. With Botox, the tactile ability to assure
deposition of neurotoxins into the proper muscular
plain is essential for best results. Likewise, when
injecting dermal or subdermal llers, the desired
outcome is directly impacted by the operators ability to
use tactile skill to make the proper quantity and
location of deposition. The technical skill required is far
less than that applied to the nishing line of a crown
prep. There is no comparative experience for our
medical colleagues or the nurses to whom they may
delegate such tasks. Suce it to say that the skill set
necessary to administer a posterior, inferior alveolar

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Journal of Esthetic and Restorative Dentistry

nerve block far exceeds that necessary to properly

augment the vermillion border of the lip or a nasolabial
fold with injectable llers.
Another imperative in determining appropriate
standard of care is consideration of the risk/benet
ratio. The risks involved in neurotoxin and injectable
ller administration must be put into context. The
inadvertent intravascular injection of Lidocaine with
epinephrine or air emphysema in the buccal tissues is
uncomfortable and undesirable. As we know, these
conditions resolve spontaneously with few, if any,
long-term consequences. Similarly, it is possible to
produce unsymmetrical results with over or under
injection of ller. Likewise, undertreatment with
neurotoxins may cause inadequate attenuation of
muscle activity. These conditions are painless and
transient. The management of such results is to retreat
or allow an expectant course of spontaneous resolution.
True complications are exceedingly rare and limited in
their extent of severity.7
Reasonable argument for why the dentists may be the
best provider for these services is a matter of history.
Certain conditions like excessive gingival show
producing a gummy smile have treatment alternatives
that are invasive and variably successful.8 One of the
earliest nonsurgical treatments of the high smile line
did not come from the medical literature, but from an
investigative orthodontist, Dr. Mario Polo.910 In 2005,
Polo published his reference paper on the use of Botox
to attenuate hypertonicity of the levator labii superioris
in order to improve the tooth/lip relationship. The
standard treatment had been the Le Forte 1 maxillary
down fracture with its more protracted recovery and
potential complications. Indeed, the less-invasive
vestibuloplasties to improve the distracting smile
characteristic of vertical maxillary excess was
popularized in the periodontal literature.11 On the other
hand, one of the rst articles by medical doctors to
appear in the medical literature for pharmacological
treatment of the gummy smile was not published until
June 2012.12 In April 2012, the American Academy of
Neurology reported the results of 2 studies indicating
that Botox injections can provide relief to patients who
suer from nocturnal bruxism. Much earlier initial

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reports on the ecacy of this treatment were made by

Louis Malcmacher, DDS, and his clinical team at the
American Academy of Facial Esthetics. What is
germane in this thread is that some of the most
insightful esthetic treatments aecting the perioral area
were claimed and sequestered by our medical
colleagues when they actually nd their genesis and
promulgation in dentistry. To their credit, the medical
profession is beginning to consider how enhanced
appearance can be used to positively aect quality of
life. This cognizance was evidenced in an article
appearing in the Journal of the American Association
entitled Rethinking the Approach to Beauty in
Medicine.13
If the evidence is so intuitive that the dentist is well
trained and possesses the essential skill set to include
these adjunctive services in their treatment
armamentarium, why the controversy? In the United
States, the key entity in establishing scopes of
professional practice is the state regulatory board. We
looked in the mirror and the enemy was us. It has been
my observation that those dental boards have
progressive, forward-thinking members who have
always prevailed in securing the statutory authority for
their licensees to selectively administer neurotoxins and
injectable llers. Appropriately, in most instances, there
is a mandate for proven prociency, and not
infrequently, diagnostic specicity. Typical provisions
include language like that issued in an advisory opinion
published by the South Carolina Board of Dentistry:
. . . procedures of this nature are limited to the perioral
area; the licensee must provide documentation
acceptable to the Board as to the licensees training,
education, credentials and qualications; procedures of
this nature may be performed by the general dentist
. . .14 Even in those states where there has been a
forceful contest from the medical profession, like
California, the dental boards have prevailed. The
dening point is whether respective dental boards have
been willing to present the facts to the relative
legislative bodies on behalf of their licensees. The
objections raised from outside entities for dentist to be
able to use neurotoxins and injectable llers in
appropriate fashion are embodied succinctly in Samuel
Clemens quote, when they say it is not the money, it is

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the principle . . . it is the money. Such as is the nature

of most turf wars.
According to the latest releases from the American
Dental Association, over 20 states now endorse general
dentist administration of neurotoxins and intradermal
llers for functional and cosmetic indications. The
American Academy of Facial Esthetics reports that 35
states allow dentist to do both facial esthetic and
therapeutic procedures with Botox and dermal llers.
Indeed, in some states, dentists are permitted to
delegate these procedures to nurses. Virtually all states
in the United States and many provinces in Canada
allow the dentist neurotoxin and injectable ller
privileges when there is a pathological indication
involving the masticatory apparatus or the immediate
adjacent oral structures. Although the matter is highly
dynamic, currently 2 states, Nevada and North
Carolina, do not consider either modality within the
scope of dental practice for their licensees. In Western
Europe, the Royal College of Surgeons and the
European Committee on Standardization have
recognized that only trained doctors, nurses and
dentists should provide non surgical cosmetic
treatments, such as neurotoxins and cutaneous llers.
What is ironic is that the challenges for qualication
are not coming from reluctant dental boards or other
health care professionals but rather from the beauty
care industry. Cosmetologists and hairdressers are
contending that their inability to use nonsurgical
interventions like Botox and llers is an unfair
restriction of trade.
In conclusion, the dentist is as well trained if not better
trained than their medical counterparts to administer
dental-related neurotoxins and injectable llers. It
should not be imposed nor should it be expected that
every dentist should oer these services. However,
certainly, they should not be denied the right based on
arbitrary and capricious restrictions emanating from
little more than turf protection. From our earliest
training in oral diagnosis, we are exhorted to aord our
patients a diagnosis and treatment plan that considers
the indications, limitations, and alternatives for remedy.
The matter is no less important when it comes to
optimizing the patients esthetic concerns. Indeed,

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I would submit that the dentist has the ability to oer a

comprehensive quality outcome that is likely to surpass
the conventional nondental alternatives.

6.

The TRUTH is incontrovertible; malice may attack

it, ignorance may deride it, but in the end, there it is.
(Winston Churchill)

8.

7.

9.

The choice is ours and the patients deserve it.

Louis E. Costa* II, DMD, MD

10.

11.

REFERENCES
12.
1.

2.

3.

4.

5.

Flanary C. The psychology of appearance and the

psychological impact of surgical alteration of the face.
Bell wed modur practice in orthodontic and
reconstructive surgery, vol. 1. Philadelphia (PA): WB
Sanders Co.; 1992, pp. 221.
Adams G. Physical attractiveness research: toward a
developmental psychology of beauty. Hum Dev
1977;20:21739.
Costa LE. Surgical management of the facial saft and hard
tissues to enhance facial esthetics. In: McNamara JA,
Kapila S, editors. Surgical enhancements of orthodontic
treatment, vol. 47, Craniofacial Growth Series. Ann Arbor
(MI): The University of Michigan; 2009.
Ackermur JL, Prot WR, Sarver DM. The emerging soft
tissue paradigm in orthodontic diagnosis and treatment
planning. Clin Orthod Reg 1999;2:4952.
Goldstein R. Change your smile, 3rd ed. Carol Stream
(IL): Quintessence Publishing Co. Inc; 1997.

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Journal of Esthetic and Restorative Dentistry

13.

14.

Sarver DM. Esthetic orthodontics and orthognathic

surgery. St Loius (MO): Mosby; 1997.
Levy LL, Emer JJ. Complications of minimally invasive
cosmetic procedures: prevention and management.
J Cutan Aesthetic Surgery 2012;5(2):12132.
Prot WR, Jurvey T, Phillips C. The hierarchy of stability
and predictability in orthognathic surgery with rigid
xation. Head Face Med 2007;3:21.
Polo M. Botulinum toxin type A in the treatment of
excessive gingival display. Am J Orthod Dento facial
Orthop 2005;127:2148.
Polo MA. A simplied method for smile enhancement:
botulinum toxin injection for gummy smile. Plast
Reconstr Surg 2013;131:9345.
Perenack J. Treatment options to optimize display of
anterior dental esthetics. J Oral Maxillofac Surg
2005;63:163441.
Sucupira E, Abramovitz A. A simplied method for smile
enhancement: botulinum toxin injection for the gummy
smile. Plastic Reconst Surg. 2012;129:72631.
Huang AJ. Rethinking the approach to beauty in
medicine. Journal American Medical Association
2001;286(17):2158.
South Carolina Code of Laws, Title 40, Chapter 15.

Reprint requests: Louis E. Costa, DMD, MD, 247 Calhoun Street,

Charleston, SC 29401, USA; email: louiecosta@hotmail.com
*Dr. Costa is licensed in dentistry and medicine. He is board-certified in
otolaryngology, and head and neck surgery, and board-certified in facial
plastic and reconstructive surgery. He is a clinical professor of facial plastic
surgery and clinical instructor of dermatology at the Medical University of
South Carolina. He is a clinical professor of oral and maxillo-facial surgery
at the Medical University of Alabama. Dr. Costa is currently the president of
the South Carolina Board of Medicine.

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