By Anne Blythe
In the minds of many, Botox once was relegated to the beauty routines of the Hollywood elite.
Then came the so-called “Zoom boom” of the pandemic where people spent hours staring into a computer screen that seemed to magnify every facial imperfection, real or perceived.
The American Plastic Surgery Association noted an uptick in 2020 for requests for botulinum toxin type A, the chemical name for the cosmetic injectable that temporarily reduces crow’s feet, frown lines and facial creases. “BroTox” became a thing for men, too.
Now you can get Botox at your dentist’s office in North Carolina.
Slow down a bit if you were about to rush out to your oral health care provider to have them smooth out those creases and wrinkles that have been glaring back from the computer screens.
That’s a no-no for dentists in this state, according to the North Carolina State Board of Dental Examiners. After consulting with the state Attorney General’s office, the board says it’s OK for dentists to inject botulinum toxin into their patients in some instances, but issued guidance earlier this year for what falls within the scope of practicing dentistry.
North Carolina has a four-page statute that defines the extent of such practice.
“Currently, cosmetic procedures and cosmetic drug or chemical enhancements of the face for purely aesthetic purposes are being marketed to dentists as a means to enhance the type of services offered by a dental practice,” according to the dental board’s “interpretive statement”.
The statement goes on to say that it’s the board’s position that the use of Botox and other drugs for “cosmetic facial procedures” should be considered to be outside the approved practice of dentistry, “…, as it does not involve the treatment of the teeth, gums, alveolar process, jaws, maxilla, mandible, or adjacent tissues or structures of the oral cavity, and is not being used as an anesthetic.”
There are some reasons, the board acknowledged, for dentists to inject Botox.
The drug might be used to relax a stiff and painful temporomandibular joint. Oral surgeons use it to help with reconstructive surgery, such as to realign a jaw or repair a cleft palate.
“[A] properly trained general dentist could be allowed to use Botox® (botulinum toxin) to treat a dental condition where there is sufficient credible scientific evidence that such use meets the standard of care for the treatment of the diagnosed dental condition. ..,” according to the statement.
Bobby White, chief executive officer of the state dental board, elaborated recently on why such a statement was posted in February. There was no complaint behind the guidance, according to White, but dentists had been asking the board to address the issue.
“What we’re saying is if we get a complaint, this is how we’ll deal with it,” White said.
Hodgepodge of advice
Dentists in other parts of the country and world have been administering Botox for purely aesthetic reasons for years.
After two lawsuits were filed in South Korea testing the breadth of practice for dentists, the country’s supreme court ruled that dentists who had been using the injectables and lasers for cosmetic procedures were not providing a purely medical practice, according to commentary from dentist Young-Jun Choi published in February in the Journal of the American Dental Association.
In this country, though, different states have individual laws defining what’s considered dentistry inside their borders, leading to a hodgepodge of guidance for dental practices in each state.
That can engender territorial questions between specialists such as one that played out in South Carolina several years ago.
In 2017, the South Carolina Board of Dentistry issued a statement with support from the state’s medical and nursing boards giving dentists permission to inject botulinum toxin neuromodulators for cosmetic purposes.
The American Society of Plastic Surgeons joined forces with the South Carolina Society of Plastic Surgeons to oppose what they described as an attempted scope of practice “creep.”
That prompted a letter dated Sept. 10, 2018, from Jeffrey E. Janis, then-president of the American Society of Plastic Surgeons, and M. Lance Tavana, then-president of the South Carolina Society of Plastic Surgeons, to Dennis A. Martin, then-president of the S.C. dental board.
“There are serious patient risks involved with allowing these injections into the dental scope of practice given the fact that dentists lack clinical training to perform surgery outside of the oral cavity,” Janis and Tavana stated in the letter.
“For example, a surgical error of just a few millimeters can result in a punctured eyeball with resulting catastrophic vision loss. Such errors could also result in a perforated blood vessel, which connects to the back of the eye and can cause immediate and permanent vision loss. Another severe risk is misdiagnosing a cancerous lesion as benign, and then improperly injecting it, which can result in the spread of cancer.”
The proposed rule was withdrawn from the South Carolina dental board’s agenda in December 2018, and the American Society of Plastic Surgeons declared “Victory in South Carolina Dental Scope Expansion.”
Changing guidance
North Carolina had talked about the issue several years before South Carolina’s dentists and plastic surgeons clashed.
White said North Carolina’s dental board sought guidance from the attorney general’s office in 2015 and the opinion at the time was that injecting Botox went beyond the practice of dentistry. The guidance changed this year, White said, after the dental board included science reports developed in the meantime on the use of botulinum toxin by oral surgeons and dentists.
In North Carolina, someone is deemed to be practicing dentistry if they issue diagnoses, treat, operate or “prescribes for any disease, disorder, pain, deformity, injury, deficiency, defect, or other physical condition of the human teeth, gums, alveolar process, jaws, maxilla, mandible, or adjacent tissues or structures of the oral cavity,” according to state statute.
Though some states argue that the scope of dentistry includes the neck and up, White pointed out that North Carolina’s law specifies “adjacent tissues or structures” to the oral cavity. That, he contends, means smoothing out creases in the eye and brow area are off limits.
“Doing crow’s feet, that would be a kind of plastic surgery,” White said. “The board’s position is that would be outside the scope of dentistry.”
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By this reasoning, dentists can inject Botox to smooth smokers lines, Marionette lines, gingival papilla’s, and chins but not forehead and crows feet. When dentists take courses to be accredited, it is generally comprehensive including all areas that can be administered with Botox. In Georgia dentists have to be both accredited in dermal fillers as well as Botox just to be able to inject Botox. I took the course to aid in TMJ treatments when splint therapy is not enough but some patients ask for other areas to enhance esthetics while treating TMJ and migraines.
The complaints about dentists, whom have extensive training in both injections and facial anatomy, from plastic surgeons, is clearly a territorial move on Botox. Botox itself, administered in such small quantities, has a very good safety profile. One can’t seriously argue that a general physician or a nurse practitioner is more educated about facial anatomy or injections than dentists. Xeomin, for example, lasts on average 3-5 mos. Doesn’t it make sense to have it done at the dentist, whom one sees every 6 mos. This ruling is nothing more than power play and fueled by greed from the medical profession.
The pandemic’s so-called “Zoom boom,” in which individuals spent hours staring into a computer screen that seemed to amplify every face flaw, real or perceived. Thank you!