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Cosmetic dentistry is more than teeth

Article-Cosmetic dentistry is more than teeth

Dr. MalcmacherThere’s no doubt, the popularity of botulinum toxin for cosmetic use is soaring. Botox (Allergan), Dysport (Ipsen) and Xeomin (Merz) injections topped the American Society of Plastic Surgeons’ list of the five most popular minimally invasive cosmetic procedures in 2016, with 7 million procedures performed by member plastic surgeons.

While providers, from cosmetic dermatologists and cosmetic surgeons to oculoplastic, facial plastic and plastic surgeons, have traditionally claimed the cosmetic injectables’ domain, dentists are increasingly offering Botox and other neurotoxins in their practices, according to Louis Malcmacher, D.D.S., president of the American Academy of Facial Esthetics and a general and cosmetic dentist practicing in Bay Village, Ohio.

The American Academy of Facial Esthetics (AAFE) has trained about 15,000 dental professionals on the use of botulinum toxin and dermal fillers for therapeutic and aesthetic uses, he says.

“Yes, it is very popular among dentists,” Dr. Malcmacher says. “The AAFE gives nearly 200 live patient training courses a year in the use of Botox and dermal fillers in North America and courses internationally. We are now seeing dental schools have Botox training in their curriculums, with the University of Washington School of Dentistry being the first to teach this to their senior students.”

Adding botulinum toxin procedures to the dental practice can be lucrative, boosting practice revenue to the tune of $125,000 annually, according to the e-book “Ultimate Business Guide to Facial Aesthetics,” by Warren Roberts, D.M.D., cofounder and clinical director, Pacific Training Institute for Facial Aesthetics.

But it also can be risky if the provider isn’t properly trained, according to Dr. Roberts. The Alberta Dental Association and College released standards that have set the bar for Canadian and U.S. dentists. Practitioners who perform botulinum toxin injections should be looking for training programs that meet these standards, according to Dr. Roberts, or they might not be covered by malpractice insurance should a problem arise. 

NEXT: A Natural Fit


A Natural Fit

Dr. RobertsFor safe, effective botulinum toxin use, providers need in-depth knowledge of head and neck anatomy. And that’s the dentist’s domain, according to Dr. Roberts.

Dentists, Dr. Roberts says, also have a leg up in their use of photography, facial marking and injection experience, which are important elements of a successful botulinum toxin practice.

“I would say 99% of our medical colleagues don’t even take photographs, and they don’t mark. But we mark and then take photographs,” Dr. Roberts says. “Dentists are gifted injectors. If you went online and went to Allergan, you’d have a physician coming dead on [with a botulinum toxin injection] to a person’s forehead. No dentist would ever inject like that. What can happen is the patient can move. And that’s only 2 mm thick, so you’re going to hit bone and dull the needle and bruise the person. A dentist automatically does what’s called a tripod, with three fingers on the patient’s face. So, if the person moves up or down, left or right, the whole hand and needle move with it. You always get into the right spot.”

Dr. Malcmacher makes the case that cosmetic dentistry is not complete if dentists just treat the teeth to make them look better.

“…this treatment is a natural extension — it is an essential treatment in the practice of dentistry today,” Dr. Malcmacher says. “The lips, lower face and, by extension, the entire face are an essential component of aesthetic dentistry. What good are beautiful-looking teeth if the lips are deficient and the lower face is sagging, so that the patient can’t even show the teeth?”

NEXT: A Functional Fit


A Functional Fit

Dr. GoldsteinRonald E. Goldstein, D.D.S., of Goldstein, Garber and Salama, DDS, in Atlanta, Ga., and author of Esthetics in Dentistry, the first comprehensive textbook on cosmetic dentistry (the 3rd edition of which will be published in 2018), takes a more cautious approach that all dentists should consider offering botulinum toxin to patients.

“One reason that a highly capable dental specialist should consider using botulinum toxin is for patients with a very high lip line and want to reduce the exposure of gingival tissue and who are not candidates for extensive surgery,” Dr. Goldstein says.

And it’s not only cosmetic patients that benefit, but there are a handful of therapeutic advantages from botulinum toxin.

“Most AAFE members are trained… to use Botox for TMJ, destructive bruxism, orofacial pain, migraines and trigger point therapy, where it is a highly effective treatment and has eliminated the frustration most dentists have had with TMJ pain cases, while… delivering excellent dental and facial aesthetics,” Dr. Malcmacher says.

Dr. Roberts says more than half of his botulinum toxin patients are not aesthetic cases; rather, they’re seeking relief for headache, temporomandibular joint (TMJ) pain or migraine. And many botulinum toxin patients have both cosmetic and therapeutic needs. By slightly changing the aesthetic template and increasing the dosage, dentists performing botulinum toxin injections can address an aesthetic concern and relieve a patient’s pain, simultaneously, according to Dr. Roberts.

Still, not everyone is so optimistic about dentists performing botulinum toxin injections. There are those who say Botox is not within the dentist’s domain.

When posed the question: “Can a Dentist Perform Botox Injections?” on, doctors from various specialties responded with different degrees of enthusiasm. Plastic surgeon Paul Vitenas, Jr., M.D., wrote Botox probably is not in the dentist’s practice scope. “Would you go to a Plastic Surgeon for a root canal or dental extractions?” he wrote

NEXT: Risk vs Reward


Risk vs Reward

The good news for dentists and their botulinum toxin patients is that effects from botulinum toxin, such as brow droop or eyelid ptosis, are reversible after three to five months, according to Dr. Roberts.

“Once it reverses, everything goes back to normal. So, the long-term effects are nil,” he says. 

Others, however, report the potential complications from botulinum toxin gone bad are more far-reaching.

“The main reason for dentists not using Botox injections in their practice is because of potential risks,” Dr. Goldstein says “A visit to Google might help one make the decision of ‘risk vs reward.’”

Researchers reported in a literature review of adverse botulinum toxin events published in 2008 that there are two classes of adverse events: transient and benign, as well as potentially serious. Among the transient and benign events: hematoma, injection site pain, intractable headache, ptosis, diplopia and hyperactivity of the local antagonist muscle, according to the authors. Potentially serious events occurred when botulinum toxin spread, “leading to botulism-like features, starting as dry and red eye, accommodation difficulty, dry mouth, gastrointestinal disturbances, dysphagia, hoarseness and lastly breathing difficulties.”

“Consensus reports say there are between 2% and 9% negative side effects from botulinum toxin. In dentistry, if I had between 2% and 9% bad implants and crowns, I’d be out of business,” Dr. Roberts says.

When they’re properly trained, dentists can avoid most side effects from botulinum toxin injections, according to Dr. Roberts. But training is key. And that means more than watching a video or taking a 45-minute tutorial.

NEXT: Know Your Anatomy


Know Your Anatomy

Dr. Malcmacher says AAFE educational botulinum toxin courses have a heavy emphasis on head and neck anatomy.

“…as that is the key to becoming proficient using these pharmaceuticals,” he says. “Dentists complete their training with AAFE mentored one-on-one live patient training, which is absolutely necessary to learning the skills needed to provide Botox and dermal fillers… for the best treatment outcomes for patients.”

Pacific Training Institute for Facial Aesthetics offers a 16 continuing education credit course to start, which focuses on anatomy. The Institute then recommends providers take the next level course, on basic botulinum toxin. Completing the two levels of training prepares the provider to use botulinum toxin to treat patients cosmetically in the upper face, as well as for bruxism. An advanced level three course trains providers to use botulinum toxin to treat patients cosmetically in the mid-face, lower-face neck and also treat myofascial pain.


Drs. Malcmacher, Goldstein and Roberts report no relevant disclosures.

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