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Botox in Dentistry Alec S. Griffin, DDS

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New and Scary

We tend to fear thipgs we don't understand.

The more informed we are about a topic more appropriate and logical decisions can be made

I recommend an in depth evidence based approach

Literature review

Continuing education

Study of political climate

DOPL & State Legislature

larry Ma= 1l1e current law does not address Botox or dermal fillers. The use of these products by dentist is neither prohibited or specifically permitted in the statute or rule. The Utah Dental Licensing Board does not make laws or recommend law changes to the Utah Legislature. To have Botox or dermal fillers specifically allowed for cosmetic use by dentist the Legislature would be the ones to add language in the Dental Practice Act ... The key portions of the above statutory language are in (7)(a)(i). If a dentist feels the treatment they are providing is within the definition of dentistry and they are within their competency based on education, training and experience they may perform treatment.

Stuart Ad;uns: Larry Marx explains well the reasons why we cannot give this practitioner a perfect answer on Botox. The law doesn't always perfectly define what may or may not be done. When tl1at is the case, we generally try to take a liberal reading of the statute to favor people trying to do business in Utah. I think you will see in Larry Marx's email that he responded much better than bureaucratically, even telling them ''The current law does not address Botox or dermal fillers. 1l1e use of these products by dentist is neither prohibited or specifically permitted in the statute or rule." Larry further guided them by saying, 11The key portions of the above statutory language are in (7)(a)(i). If a dentist feels the treatment they are providing is within the definition of dentistry and they are within their competency based on education, training and experience they may perform treatment."ln other words, when the law is unclear, we try to advise tl1em to read the law and decide how to proceed themselves. ·

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Can Dentists Administer Botox?

C1 Dr. Engar - PIE covering Botox and dermal fillers for cosmetic purposes and therapeutic uses as long as provider can prove they are properly trained.

GENERAl. DE'NfJSTS AND BOTOX

tNUTAH

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·-rn Gord We Trust

('\ Nebraska Dental Association- Recommended d1e use of Borax and

Dermal fillers in dentistry.

0 VA GPR: Teaches Botox administration

() Nebraska ADA meeting I attended in 2015

I remember~d Dr. Christiensen saying, 'De~tists are uniquely qualified to administer Botox. Who gives more injections in the face?'

I wanted to make sure I was remerhbering that correctly.so he is not misrepresented.

n I sent an E-mail to Dr: Christensen's assistant Toni Wengreen to make sure I remembered correctly. . . .

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Dr. Gordon Christensen To~l Weo{nocn ·b; AIDe GM~ir:

;~t:;. sew~:; in uum.

Dear Dr. Griffir.:: Here is Gordon's response to your email.

Alc:c: Col'lgratuiJtions on vaur lrwo~vcm~nt with the UOA·. re!atiw o:;o the Botm:. chalien13e, I feel that the entire subjl!ct is on!y pofitica! and that dentists~ properly educated, are THE MOST appropriat'J pfactitionerformany of the uses of eotox and derma fillers.

Goforlt!

Chief Operations Officer ~ Practkal Cflnic:al Courses

llmin'!!ati\'i.! ,Dire;tor • CR Foundation JY?l~tiilll~UU.ffin&re 1707 N Canyon Road, Stc. 30 ?fO\IO, Utah 84504

.... ioiJffi<e 801.226.8637 Fax

Dr. Louis Malcmacher President, AAFE (American Academy of Facial Esthetics)

0 Dr. Christiensen Recommended

n MFE courses: "fulfill medical and dental state regulatory board requirements for adequate training and have been accepted as fulfilling proper training needed for injectables."

0 "I have personally worked with many of the state medical boards and dental boards around the country in this area for the last 10 years. This includes Utah when I had a number of conversations with Noel Taxin from the DOPL at that time who oversaw the medieal and dental boards in Utah ... "

n Malpractice insurance: "TDIC, Medical Protective, at.this time most dentalliabiliry insurances either cover it or have a rider available."

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Dr·.- Malcmacher Me: "I have been working on clarifying state Botox regulations in Utah. The board has asked me to put a presentation together and I wondered if you could help me with some

. information about yourself and if there have been any issues with general dentists administering Botox in your state?" ·

Dr Malcmacher: "l am not aware of any patient clinical issues or complaints that have ever come before a dental board regarding Botox and fillers, that by itself should tell you that it is as safe if not safer than any other areas of dentistry."

"Everyone agrees this is now within 'the scope of dental practice, The AAFE has given and is giving its live patient training courses at the ADA annual meeting the last few years and this coming year. I have even done a video with Dr. Gordon Christensen on the use of Botox and fillers in dentistry. Also see some articles attached. There are now constant articles about Botox and fillers in dental journals, the attached are an example."

"The best the board will' tell you is what we already know other boards have said- if the dentist uses it within the scope of dental practice and they document is appropriately, it .is fine.· It is up to the dentist to make sure they are within the scope of dental . practice. That is what the AAFE has been teaching in Utah for nearly 10 years already."

..

Louis Malcmacher r• r~:--;.;;.:~-m-:~ f;,m~~r.;mr; A.:;)-<;.~,:'~'1 ')~ t<lC.b~ GUY><.il:l'O«

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Pmsentatioo{s):

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Botox and Dermal Fillers in Dentistry

You have Seen many references to use of Bctox and dermal fi!lcr5 by dentists.. Are you ready far some c:hangt:!s in your pracuce? wn:;. Jmo..,..-s mc1-e abt:~ut f<m<"l estht!ti:CS., oral nn~swl>lture ~od tb!:' psytho!ogy of fac:<ll <Jppetlrann: tt1.a:~ de1~iats? loul!<MO!r.Fn<>rtte~ r~ ,, weiHY:~cogni;~~

plonert~ in tnls Jf('<., omo t~1is <Jkko prc:oer.tutb!'lloc.rudes Gt>trbn ils\o:lnf. Low~s <Jll of the Qoest.-'Ons th.!!tare en /'!:<U> mlnd a~ot-1 thls s>.;O;et<_ A

dr:;c~l oerncr.~:ration on a pat1el'l~ sho-ws tne $\mpli!!t}- of_tne :::oncept Topl::s in.::.l:med ar-e: ·

Current providers

0 Physicians

n Midlevel Providers Nurse practitioners

0 Physician assistants

0 . Registered Nurses n Many providers delegate a bulk of injections to staff

0 Oral and Maxillofacial Surgeons (most states)

() Dentists (Vivaleaming: Dr Malmacher stated that almost all states allow therapeutic botox use and over thirty now allow it for cosmetic use)

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Pacific Training Institute

0 The Pacific Training Institute for Facial Aesthetics (PTI) is a Canadian company that provides training for both Canadian and U.S. providers. According to PTI, "92% of physicians pe~forming botulinum toxin [injections] have no formal training in the field of botulinum toxin, nor guidelines · laid out by their regulatory body. Physicians are not required to take any additional training in order to provide botulinum toxin or der~nal fillers." Dentists and registered nurses require postgraduate education to perform these procedures. A registered nurse may perform these services under the supervision of a physician or a dentist. These guidelines have been consistent with current legislation in th:e United States. ·

Massachusetts· 2013 Decision

r' Massachusetts approved the use of botox and dermal fillers in 2013. The group created to inVestigate the use of these_ products said, "The task force unanimously felt strongly that it's an area that dentists can definitely work irl and deliver without a problem, given our background and trai~ing.71

0 TI1e article from the ADA newsroom also states:

r:- Massachusett." dentists who want to administer Botox and fillers must be board certified in oral and maxillofacial surgery or have completed a minimum of eight hours of training in the . administration of botulinum toxins and/ or 'demial fillers that includes instruction 'in the 'anatomy of head and neck, neurophysiology,_ patient selection, pharmacological effects and contrain_dications, management of complications, informed consent and hands-on training on the administration of the agents. The training must be offered by a continuing educatiOn provider approved by the ADA's, Continuing Education Recognition Program, the AcademY 'of Ge11-eral Dentistry1s Program Approval for Continuing Education or another nationally recognized and accredited entity approved by the dental board.

() The ADA supports dentists perfonn~ng any procedure for which they are qualified by education, training and experience and consistent with the laws of the stare in which they are practicing. The Association is aware of at least 20 states that have addressed the. issue of general dentists administering_ Borax. (Soderlund).

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Massachusetts approves Botox policy for dentists k.r."f01.2DUI .

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Botox and Biosimilars

0 Botox (the eponym)

0 1. Aboboulinumtoxin A (Dysport)

0 2. lncobotulinumoxin A (Xeomin)

3. Onabotulinumtoxin A (Botox, Botox cosmetic)

0 4. Rimabotulinmtoxin B (Myobloc)

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Botox Mechanism of Action

n Botox® is considered to be in the same class as any injectable;. similar to a flu shot

() Mechanism of action:

0 The botulinum toxin is a neurotoxin that acts at the neuromuscular junction. It blocks the release of acetylcholine thereby reducing neuromuscular contractility and function. The effects of the toxin wear off over time (roughly a three month period) .as the docking proteins affected regenerate (Small). _

Adverse Reactions

. () Generally Safe

n Allergic reactions

n Rash, itching, headache, neck/back pain, muscle stiffness, difficulty swallowing, short of breath

Nausea, vomiting, sore throat

0 Spread to distant site (Black box warning)

0 Ptosis

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Contraindications

n Pregnancy/lactation (Class C)

:·:, Allergy to any of the Botox constiruents Egg protien allergy (Albumin in drug bas crossreactivity)

Drugs that can interact Aminoglycosides

Anticholinergic drugs (&other drugs affecting neuromuscular transmission)

n May potentiate the affect of Botox

('> Neuromuscular diseases . Mya.(jthenia graviS

, . Guillian-Barre Syndrome

Amyotrophic Lateral Sclerosis

"' Psychologically unstable patients

TMD

F'trn.m£ ::0:. h;m;:K;<~W.,...t<r" ~m-~~~ .... .r1!

;:,~,..

. Kranenmaker. P 10 Germain. Pp 4,5 .

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Application_s

n Botox injections have been recommended in dentistry to alleviate: ·

TMD (especially helpful for myofascial pain),

Bruxism,

Oi-omandbular dystonia,

"'· Mandibular spasm,.

·:"' Pathologic clenching,

Trismus prevention,

An adjunct for dental implant integration,

To correct gingival excess ("gummy smile")

Masseteric hypertrophy (Nayyar et aL) ..

Applications Continued

r- Other applications (to include both on and ,off label use), 7

; Wrinkle prevention

Overactive bladder

Urinary incontinen-ce

Upper limb spasticity

:·~ Cervical dystonia

Severe axillary hyperhidrosis (excess swearing)

Blepharospasm (eyelid spasm)

Strabismus (squinting)

Sialorrhea and other secretory disorders

!"'- Facial nerve palsy .

r Headaches (implortant to note ~ating migrairles should be discussed with neurology in ~m:ler to rule out any headache attributed to br:ain pathology ie masses etc).

Trigeminal neuralgia '

Facial trauma

Adjunct to' ordthOOonric treatmen't

Adjunct in denture patients (Srivastava et. Al)

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I . I

incHcatlons

AU lopit:!>. <1m u;;de~tr.d >!IS nB:w (t:M!tmt.t: oomox..>:S

~-.mMtrM r~1d ow f:t:::..) 'tt~.~:J.,::~~~:t:.:-.:.1 if', compt<llt: Uterature review current through: Dec 2.U1S. ! This topic laJt.t updat~d: Mtldl1, 2lH<L

INTROOUCTJON - Botulinwm tQX;n ts an iniecmt:m> n~~mmudu~il!k!' oun\lm} hm1 nm.~nt.oxm~ p-tru1ut;C>t by

C(osftili!Um ooWJinum. ttm bmt.er~;rn t(!t>;.<Vtl~~~~ !·:."~!

be!absm. Ttu®gh tnt! ir.hihi.llan nf r.eurc.tr~liSSltm

bf$""-utm p(l-r.cMHl! r:.trv£~ mlcings anti mv!;c~~ r"llli.ll"&,

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)~lil.:iti!y u~e6 ~d rm."if,cal ~~Jdi·::t:~!i<l;::&;. t>t>luhoum 1<J)(.::

injsc:mn has 00\"'<' t>t<come one cf~tle most ro®ested

proceduwt. .n !aci<I} ~:;~~.<annhttn

Wncn us® a;.;.:nopr',ab~y. botut:num to,in injodion is W.l

O'>~'t-r>"~!mir,q:!'f s<J'~ r.w!h<d ~."t:np:ro111ng tosfi'Jt'tl!:

duit!C:t~ that are- ~tl$iJ•.:l t;y or e.taauba:od t<y mus.-e!e wattacbon. suc.t1 as p:wm mmt g'a~lor rtl~1&Jes.. Tne

effects of oo~uhmJrn loxb. ttrtJ ~<1'1S..i.'t't nmsco<~r bnr.b<.m: IYilleti?l-,; n~!~lnt'S< w lsa:wh:~ illttwt ;:~ fe<~o momns,

Conclusion

0 We have a responsibility to be excellent for our patients

0 Dentists have an excellent foundation

n With appropriate training can provide excellent service

0 Understand pharmacology, anatomy, administration, and complications

n I recommend requiriti.g training as other states have done and as PIE requires

n 8-10 hours of hands on CE for Botox and Dermal fillers

n Supportive statement from the board as that from the Massachusetts state board to reduce liability and' make it easier to acquire the medications.

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Works Cited

PCC Dental CE Video: hnps:/ /www.pccdental.com/product~/ ce-dvd-library/borox-and-dermal-fillers-in-dentistry-2.php

hrrPs://www.pccdenral.com/uploads/files/1034Nl57Q.Complete-P:~cket.pdf

(: Cameo Collage. Esthetic Training, hrm.f/cameocollege.com/abom/

I

Cameo Collage Flier. http:/ /cameocollege.Com/dacs/ AesrhericsRyerRev.Ib-2~.pdf

~.., Monheir, Gary D. et. AI. AhobotulinumroxinA:A 25-Year History. AestheticSurgrn· Journal. 2017 May; 37(Suppll): S4-Sll. · https://www.ncbi.nlm.nih.govlnmrbrtide~/PMC543448$/

(: Nayyar, Pranav. BOTOX: Broadening the Horizo~ of Dentistry. lourn:~l of Clinical and Diagnostic Research. Vo!S (12). 2014 Dec 5. hrrps://www ncbi.nlm.nih.govlnmdarrides/PMC4316'364/

n Pacific Training Institute for Facial-Aesthetics. What Training is Required in Order ro Provide BotO:\.~ Injections? hrrps://nrifa.com/blog/bonilinum-roxin·trflining/wh:~r-rrainino-requiremenrs·;ue=necessaw·in-order·t9-Provide:botox· injes:tions/ · ·

r~ Polo, Mario. An lnterviewV~<ithA-iario Polo. Denral Press Journal of OrthodonticS. 2017 Nov-Dec; 22(6): 1:4-24. hrros://www.ncbi.nlm.nih.gov/pmclarticles/PMC57 84812/

Roral College of Dental.Surgeons of Ontario. New po~irion on the use of botulinum toxin and dermal fillers by Ontario dentis-ts. Dispatch. September/ August 2013. http://Www.redso org/KnowledgeCentre/DisnarchMaga::ine/Onlint>DispatchArrhive/Newpo~itiononrheuseofbornliml mroxinanddermal(iJ!ersbyOmariodenrim

Works Cited

:.; Additional information from Canada: hrrp://www.macleans.ca/economv/busines~/brush·flQ"-Yand-botoxl

r;, Even more Canadian "info: hrrps://www.cdsbc.org/practice-re!'lources/profe.."sional-practice/infonnation· sheer.s/bc;nox-and-dermal-fil\enAscbedu\e-1-drug~)

r;. Small, Rebecca1 M.D. Botulinum Ta-t.:in ln.iectiori for Facial Wrinkles. American Family Phy<ician. 2014 Aug 1;90(3):168-175. htros://www.aafp mg/afp/20l4/080!/p168.btml#abstract

r: Soderlund, Kelly. Massachusetts Approves Bo~o."\: Policy for Dentists. American Dental Association News. Aprill, 2013. https://www.ada org/en/publications/ada-new~/2011-archive/april/mac;sachusett.vgpprove.,.. hotox-policv~for-dentist!'l

Srivastava1 Sailjeev et at Applications of botulinum toxin in dentistry: A comprehensive review.~ Journal of Maxillofacial Surnery. 2015 jul-Dec; 6(2): 152-159. httns://www.ncbi.nlm.nih.gov/omc/articles/PMC4922224/

Stev,rart, Kirsten. How should Utah regulate the pursuit of J,Jeauty? Salt Lake" Tribune. Feb. 28, 2011. http://archive.!'l!trib.com/arricle.php?id"'Sl305195&itvpe"'CMSID

The American Association of Dental Boards (MOB). Licencing Requirements: Chari: 35 -"Regulation of Hyaluronic Acid and Dermal Fillers and Botulism type "A" for Dentists." https;//denralboa:ds.org/ymducr/th?-composjte·28th-edition/.

n Additional state by state resource guide: https://wwv.· empiremedicaltraining.com/webSite/doc!'l/dental­regulations.odf

I

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Works Cited

(;. Winn, Washington, .Jr. er.al. Koneman'~ Color Arbs and T exrboo_k of Dbgnosjc Microbjology. 6th ed. Pp 937-938.

Additional Articles Not Referenced

Abdel Aly, Lobna et al. Borox as an adjunct to lip repositioning for the management of excessive gif!gival displa}' in the presence of hypermobiliry of upper lip and vertical rnaxillarv excess. Dental Research Iournal. 2016 Nov-Dec; 13(6): 478-i!-83. hmw//wwy.,· ncbi nhn nih.gnv/nmc/arrjc\es/PMC5"~560IO/

American Academy of Facial Aesthetics. DENTISTS DOING BOTO~ IT'S ABOUT TIME! July 10, 2014 hrrps·lfwww facia!esrherics.org/blop/denrjsrs-borox-tirne/

Asutay, Fatih et al. The Evaluation of the Clinical Effects of Botulinum Toxin on Nocturnal Bruxism.~ _and Management 2017; 2~17: 6264146. hrrns·lt'wvro,.·.ncbi nlrn nih gqv/pmdarrirles/PMC5516743/

~aker~Ja.son S. Effectiveness of botulinum toxin type A for the treatment of chronic masticatory myofascial pain. h'lmfMfd';;t,;;og~~.~f.fo'lllfi:lffi\'{lg\Xdoof~"' 2011. Volume 148lssue L Pp 33·39.

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t'J Germain, Lisa. Et al. Compendium. Frontline Temporomandibular Joint/Orofacial Pain Therapy for Every Dental Practice. Volume 38: No 5. Mar ~Ol7. pp 2-8.

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