Broadening Dental Practice With Cosmetic Injections

Cosmetic injectors are not the only trained practitioners who provide Botox as a solution. Dentists are trained in the administration of Botox to treat oral conditions, including temporomandibular joint disorders (TMDs), parafunctional clenching, and teeth grinding. Dentists typically have more extensive knowledge about the oral and maxillofacial areas than most healthcare professionals. However, they do not have experience injecting Botox for esthetic purposes, but with the right training, they could.

In March 2022, Arizona Governor Doug Ducey signed a bill allowing dentists to inject Botox as a cosmetic treatment.¹ Removing this cosmetic restriction from the law is expected to open doors for dentists who have used Botox solely as a medical treatment. They can now treat the face globally with cosmetic injectables, which means they can broaden their practice with multiple streams of income.

Bacterium Clostridium botulinum produces a protein and neurotoxin called botulinum toxin. Botulinum toxin is produced by the microbe that causes botulism, a type of food poisoning that can be life-threatening. However, the potential of botulinum toxins for medical treatments was first recognized by the German physician Justinus Kerner in the late 1800s, who referred to the toxin as a "sausage poison" after he ingested spoiled sausage. Another German physician, John Muller, later changed the term from "sausage poison" to "botulism."²

Today, thanks in part to the German physician's discoveries, healthcare professionals use Botox in small doses to treat medical conditions. While there are seven types of botulinum toxin, lettered A through G, only two (types A and B) are commercially available for cosmetic and medical procedures.³ In 1949, Burgen et al discovered that type A toxin can block neuromuscular transmissions.⁴ Then, in 1989, the FDA approved Botox for therapeutic use, and it was then rebranded to Allergan Aesthetics' (an AbbVie company) BOTOX^® (onabotulinumtoxinA). Thirteen years later, the FDA approved BOTOX^® Cosmetic (Allergan Aesthetics) to temporarily improve moderate to severe glabellar lines, also known as the frown lines between the eyebrows.⁵ Then, between 2013 and 2017, BOTOX Cosmetic was FDA-approved for temporarily improving the appearance of moderate to severe lateral canthal lines and forehead lines in adults.⁶

BOTOX (onabotulinumtoxinA) was the first drug to use botulinum toxin to prevent a muscle from moving temporarily. The three other forms of botulinum toxin type A are Dysport (abobotulinumtoxinA), Xeomin (incobotulinumtoxinA), and JEUVEAU^® (prabotulinumtoxinA-xvfs). Several companies are rapidly investigating the use of botulinum toxin type A for a longer duration, such as the new FDA-approved Revance Botox product, DAXXIFY^™.⁷ However, each product is different with regard to dosage units, duration of efficacy, and onset of action.

When botulinum toxin is injected into the desired treatment area, it binds to the nerve. Once the nerve internalizes botulinum toxin type A, it stops the release of acetylcholine, a neurotransmitter. Without the release of acetylcholine, muscle activity will stop, causing the neuromuscular blocking effect, weakening the muscle for 3 to 4 months.³

Botulinum toxin type A is primarily used in medical spas for treating wrinkles and fine lines but also can be used for various dental conditions, such as:

Temporomandibular joint disorders. TMDs cause pain and dysfunction in the jaw and the muscles that control the movement of the jaw. Botulinum toxin type A works by relaxing the jaw muscles and reducing muscle spasms and pain.⁸

Bruxism. Grinding, clenching, or gnashing teeth can lead to damaged teeth, jaw pain, and headaches. Studies show that using botulinum toxin type A decreases bruxism symptoms.⁹

Dental implant treatment and surgery. Botox relaxes the masticatory muscles to help create a stable environment for implants and allow for fewer miniplate and/or microplate insertions in a patient.³

Gummy smiles. Both a medical and cosmetic issue, a gummy smile is an excessive display of gingival tissue in the maxilla upon smiling. Small doses of botulinum toxin type A injected into the lip elevator muscles limit the exposure of the upper gum when smiling.¹⁰

Although dentists already use Botox for medical purposes, injecting patients for cosmetic purposes requires different proficiencies. Now that state laws are changing, dentists can inject Botox for cosmetic treatments; however, they need to understand how to enhance facial esthetics with an artistic eye rather than a medical approach, and know where and how to inject it for the best esthetic outcome.

For example, patients may be interested in the use of Botox for the correction of an asymmetric smile. A study showed that 96 hours after injection of BOTOX Cosmetic into the muscles surrounding the lip, depending on the asymmetry of the patient's smile, smile asymmetry correction was achieved. According to the study, the patients' symmetrical smiles lasted approximately 5.5 months after their first treatment and 6 to 8 months after subsequent treatments.¹¹

Adding cosmetic injections to the array of services a dental practice can offer gives patients the opportunity to have their glabellar lines softened. Glabellar lines occur naturally over time. A study showed that 20-unit doses of BOTOX Cosmetic were significantly more effective at reducing glabellar lines than smaller doses in women.¹² In men, however, larger doses of botulinum toxin type A were needed to improve and soften glabellar lines.¹² Botulinum toxin type A is not a one-size-fits-all treatment. If dentists want to treat glabellar lines on their patients, they should understand the dosing amount for each patient depending on the treatment area, such as between the eyebrows for the appearance of lines.

Horizontal rhytids appear in the frontalis, located in the anterior forehead region, and may cause continuous bands across the forehead or appear V-shaped with an absence of a midline frontalis muscle.¹³ With botulinum toxin type A injections, the frontalis will relax, causing rhytids to soften. In addition, with correct pattern placement, botulinum toxin type A injected in the frontalis muscle will increase hypermobility in the corrugators, causing an esthetically pleasing awake and refreshed appearance.

Lateral canthus rhytids, also known as "crow's feet," are an early indication of the appearance of aging. Injecting botulinum toxin type A is an ideal treatment for "crow's feet," targeting the underlying muscular pathology causing them.¹⁴

Broadening a dental practice's offerings with highly desired cosmetic injection techniques can propel the business forward. Botox is a minimally invasive, nonsurgical treatment that can achieve both cosmetic and medical outcomes. However, training for cosmetic injectables like Botox requires focusing on and reviewing facial anatomy and physiology to help build confidence in treating patients for cosmetic procedures with an artistic approach.

Emily Tryon, RN
Associate Degree Nursing, University of South Carolina Upstate, Spartanburg, South Carolina; Chief Executive Officer and Founder, Esthetic Breakthrough Training^™ and Esthetic Solutions^™ Med Spa, Scottsdale, Arizona