Leaders in Dentistry: A conversation with Dr. Louis Malcmacher

DrBicuspid.com is pleased to present the next installment of Leaders in Dentistry, a series of interviews with researchers, practitioners, and opinion leaders who are influencing the practice of dentistry.

We talked with Louis Malcmacher, DDS, a practicing general dentist, lecturer, author, evaluator emeritus for Clinicians Report, and current president of the American Academy of Facial Esthetics. Dr. Malcmacher, who teaches courses on how to inject Botox, believes that dentists are among the best qualified healthcare professionals to deliver Botox therapy.

He discussed the growing use of Botox in dentistry for both aesthetic and therapeutic purposes, and whether the opposition from dermatologists and plastic surgeons is really about patient safety, or simply a turf war.

DrBicuspid: How many states allow dentists to administer Botox, and how many U.S. dentists now offer Botox in their practices? Is this number growing, and do you expect this trend to continue?

Louis Malcmacher, DDS, president, American Academy of Facial Esthetics

Louis Malcmacher, DDS, president, American Academy of Facial Esthetics

Dr. Malcmacher: About 98% of U.S. states allow dentists to administer Botox for therapeutic purposes to treat conditions such as facial pain, bruxism, and temporomandibular joint (TMJ) disorders, and more than 35 states allow its use for both therapeutic and cosmetic purposes.

The use of Botox in dentistry is definitely growing, and 16% to 20% of dentists in the U.S. now offer it in their practice. It is by far the fastest-growing area of dentistry.

In your experience leading seminars that teach dentists how to administer Botox and dermal fillers, what do you find to be the primary motivation behind their desire to learn this procedure -- cosmetic, therapeutic, or financial?

At the American Academy of Facial Esthetics we teach more than 50 courses a year on Botox to healthcare professionals, primarily dentists. We have trained more than 3,000 dental professionals from 46 U.S. states and 30 countries, and we have found that they want to learn for a variety of reasons.

Dentists are always looking to add new procedures to their practice. Even though Botox in terms of a dental therapeutic has been around for almost 20 years, it just recently started getting attention. Previously, dentists were unsure whether states allowed them to use Botox, but now that a lot of states allow it, they want to learn.

Dentists have always done aesthetic work, but consider this: What if you give your patient perfect teeth using crowns or veneers but they have wrinkles around the mouth? They still won't have a perfect smile. With the use of Botox, dentists can change that and create the perfect smile. It really gives them the best possible aesthetic outcomes. Also, it is also a great therapeutic option for treating orthodontic relapse, and conditions such as TMJ disorders, facial pain, bruxism and clenching, and gummy smiles.

As for the financial motivation behind learning Botox, it is no different from their motivation to learn other profitable dental procedures, such as implants, veneers, and whitening.

Dentists are always looking for the best treatment options for their patients -- be it for therapeutic or cosmetic purposes. Botox is a great tool in their toolbox for excellent aesthetic and therapeutic outcomes when integrated into dental treatment plans.

Opponents say that Botox is best left to plastic surgeons and dermatologists. But you have argued that dentists are more qualified because they give more injections. Is this a turf war, or is patient safety really at stake?

This is nothing more than a turf war. Patient safety is not an issue. If you look at healthcare professionals, overall dentists have the best safety record. They pay the least amount of money in malpractice insurance, which should tell you how low our risk really is.

Plastic surgeons and dermatologists don't just want to keep dentists out, they want to keep every other physician -- including ob/gyns, ophthalmologists, and registered nurses -- from giving Botox as well. That should pretty much prove that this is a turf war. We do occasionally find the same thing in dentistry, which is unfortunate and not at all necessary.

We train all kinds of healthcare professionals at the American Academy of Facial Esthetics, and dentists are the most conservative in their treatment approach. Also, they give the most injections and are the best at giving them.

We have trained thousands of dental professionals who have given more than 25,000 injections at our courses and have not had a patient safety issue.

Do general dentists need special training to give Botox injections?

Dentists absolutely need training before they can use Botox and dermal fillers. These are pharmaceuticals, and it is crucial that dentists get live patient, hands-on training before using these materials.

No state will allow them to use Botox -- and certainly no insurance company will insure them -- if they do not complete the requisite training. All states require at least a 16-hour training course, which should include one-on-one mentored instruction.

Having said that, dentists are absolutely qualified to use Botox and dermal fillers. They understand lip lines and lip volume, and overall have extensive aesthetic knowledge when it comes to the oral and maxillofacial region. If they can do veneers and extractions, Botox and dermal fillers are comparatively much less invasive procedures.

Dentists just have to learn the anatomy, physiology, and pharmacology, and should know how to deal with adverse reactions and especially how to avoid complications.

Apart from the cosmetic benefits, Botox can also be used for therapeutic purposes. Are there any indications dentists should not be using it for?

Dentists should only use Botox in the oral and maxillofacial region. There are lots of uses for Botox below the chin, but dentists should stay away from those areas.

Are there potential legal implications for dentists resulting from adverse Botox outcomes?

It is not an area of concern at all, and I have personally not heard of a malpractice lawsuit resulting from Botox. Dentists need to be well-trained and have proof of their training, and we strongly recommend that they have malpractice liability insurance before administering Botox. Many dental malpractice insurance companies now will cover these procedures.

Besides, Botox and dermal fillers are temporary procedures and do not cause long-term side effects. Nationally, lawsuits in this area are very low across both medicine and dentistry.

What is your position on dermal fillers? Should dentists be offering them also?

Botox and dermal fillers go hand in hand. They are more than complementary. There are clinical situations where you can't do one without the other if you want the best outcomes for your patients.

Also, dermal fillers have now become very exciting for dentists. Until recently, they were only used outside the mouth for volumizing nasolabial folds, lips, cheeks, and all of the soft tissue in the perioral area, but now there are more and more intraoral uses for dermal fillers. For example, they can be used to eliminate black triangles between teeth after periodontal and implant treatment that did not pre­serve the papilla or to treat gummy smiles, among many other indications.

Does similar opposition exist with regard to dentists doing dermal fillers?

It is hard to oppose dentists performing dermal filler procedures since they are placed in the exact same area that dentists treat on a daily basis.