A Review on the Expanding Role of Dentists in Facial Esthetics

ABSTRACT

Dentists’ role in facial esthetics is growing, with advancements in cosmetic procedures, such as Botox and dermal fillers. Understanding the range of practitioners and their professional backgrounds is crucial for addressing risks. Data collection and analysis was done to retrieve scholarly papers using databases, such as PubMed and advanced Google search, and analyze. Currently, the role of dentists in facial beauty is gaining huge interest. This is a new and controversial issue in this era of society. Botox and dermal fillers help general dentists create a harmonious smile by controlling soft tissues. Further training may be required to perform esthetic procedures, such as Botox or dermal fillers, in areas other than the perioral region. Complications might occur due to inadequate education. Dentists must be competent to administer these agents, such as traditional providers. The review paper concludes that dentistry students are becoming more interested in cosmetic treatments. Cosmetic practice in dental education may be strengthened by combining topics, such as dermal fillers in materials science, botulinum toxin (BTX) in pharmacology, and anatomy of the aging face in dentistry with emphasis on medicolegal laws, policies, and ethics involved.

INTRODUCTION

Dentists’ role in facial esthetics is growing, with advancements in cosmetic procedures, such as Botox and dermal fillers.[1] Understanding the range of practitioners and their professional backgrounds is crucial for addressing risks and introducing licensing to the industry.[2,3]

Garner in 1997 had described a surge in demand for non-surgical facial aesthetics (NSFA), encompassing the application of dermal fillers and botulinum toxin (BTX).[4] As the scope of cosmetic dentistry has expanded, modern dentists ought to educate oneself with the myriad of options that have emerged. As regulations pertaining to their usage in dental clinics continue to change, Botox and dermal fillers may seem like the logical next steps in cosmetic dentistry.[1] By using botulinum toxin type A (BTA) and dermal fillers, general dentists may better produce a harmonious smile by controlling the soft tissues surrounding their mouth. To get the right results, BTA and fillers must be injected carefully into the dermis and musculature of the face.[5]

Demand for dermal fillers and BTX is rising.[6] In response to these increased needs, practitioners, including nurses, physicians, dentists, and beauty therapists, are now providing services in esthetic clinics, dentistry offices, and beauty bars.[2] The dentist who administers BTA and dermal fillers must be as skilled as other medical professionals who have historically served as the gatekeepers of these agents, which includes having a solid grasp of the mechanisms of action and the capacity to handle any issues or complications. However, currently, there is not any undergraduate curriculum-based education available right now to properly train dental practitioners in NSFA.[5]

Our review will highlight the importance of understanding the range of dental practitioners and their professional backgrounds in addressing potential risks to patients while providing these treatments and understanding the importance of training and licensing.

METHODOLOGY

Advanced Google search and PubMed were the main sources of search, and the keywords used were Botox, fillers, dentists, and cosmetic dental treatment. Around 30 articles were selected after screening by the authors. The research papers analyzed by the authors covered a variety of methodologies, including clinical trials, surveys, systematic reviews, and case studies. Each research paper followed a specific methodology tailored to its objectives, population, and research design.

AIMS

To explore dentist’s role in facial esthetics and analyze scientific support.

OBJECTIVES

To evaluate safety and efficacy of different esthetic treatment modalities performed by dentists and to assess training adequacy.

DISCUSSION

Various chemicals used in cosmetic treatment, their application, and any issues reported are discussed.

Platelet-rich plasma (PRP)

Platelet-rich plasma (PRP) injections are widely used in cosmetic treatment to rejuvenate skin. A kind of autologous plasma known as PRP has a higher concentration of platelets than whole blood.[7] After platelets are activated either endogenously or exogenously, growth factors are generated, which have the ability to both directly and indirectly repair tissue. PRP draws fibroblasts and mesenchymal stem cells, promoting their growth and improving the quality of the skin.[8]

With the rising popularity of elective cosmetic operations, cosmetic dentistry has grown to signify more and more to patients, and dentists, when it comes to improving one’s overall face esthetics. Dramatic results may be obtained by combining the essential concepts of good smile design into a comprehensive treatment plan for face esthetic enhancement. As there is no official regulation, healthcare professionals with training in anatomy, physiology, and pharmacology can work as esthetic practitioners without needing a license and there is not any curriculum-based undergraduate instruction for healthcare workers to receive a formal education on NSFA.[6]

The study conducted by Aust and his colleagues evaluated how much PRP injections improved cosmetic results and patient satisfaction. Treatments that are well-established, such as autologous fat transfers and blepharoplasties, may come with substantial risks. An ideal substitute would be a minimally invasive procedure, such as PRP, which clearly improves aging skin problems, cutis laxa, and volume loss while presenting minimal risk to the patient. The results of the cutometer tests showed a statistically significant increase in skin elasticity and a statistically significant higher level of skin firmness. There were no additional unfavorable side effects or problems, and there had been no reports of the usual burning feeling during the injection.[8] Another literature search turned up no instances of complications, suggesting that PRP is low-risk and safe. In a trial with a placebo, the PRP group’s average collagen optical density increased by 89.05%.[9]

Hyaluronic acid (HA)

Hyaluronic acid (HA) is a glycosaminoglycan that is necessary for the extracellular matrix. It promotes cell migration, proliferation, and interaction with several growth factors to aid in tissue repair and wound healing. Furthermore, because HA is hygroscopic, it plays a critical function in space-filling.[10] It contributes to the preservation of the structural and homeostatic integrity of tissues by controlling osmotic pressure and improving tissue lubrication and resilience.[11] These dermal fillers provide transient and reversible health advantages in addition to filling up wrinkles, creases, and lines.[12]

The interdental papillary deficit, sometimes referred to as “the black triangle,” is the third most unpopular esthetic issue after crown edges and cavities, making it a serious concern for both patients and dentists. By permitting air and saliva access, it causes chronic retention of food debris, problems with periodontal health, and phonetic difficulties.[13] The inadequate blood supply of the tiny, fragile interdental papilla poses a fundamental limitation to surgical and augmentation procedures, making reconstruction of this deformity difficult. Fillers are being used successfully to treat black triangles to complete the esthetics.[14] The product utilized to treat the black triangle in a study was a cross-linked HA filler stabilized without using animals called Restylane-Lidocaine. In 2003, the Food and Drug Administration (FDA) authorized Restylane as the first HA filler, and it lasts for around 6 months. A more recent formulation called Restylane-Lidocaine, which has 0.3% Lidocaine integrated into the syringe, was utilized successfully in another research.[15]

Botox

Botox is a wrinkle-reducing cosmetic therapy that has been used for many therapeutic purposes in medicine, including the treatment of strabismus, cervical dystonia, blepharospasm, and hyperhidrosis.[16] Its therapeutic applications in treating specific oral disorders have also contributed to its growing appeal in dentistry. General dentists are permitted to administer Botox and dermal fillers as long as they have the necessary education and expertise, according to the Dental Quality Assurance Commission of Washington. Injections of BTA reduce the activity of hyperactive muscles, hence blocking the release of acetylcholine by the cell. The muscle is weakened for 3 to 4 months as a result. For a number of oral problems, including bruxism, or oromandibular dystonia (OMD), and temporomandibular joint disorders, BTA can be utilized.[17] Its increasing popularity in dentistry is partly a result of its therapeutic uses in the treatment of oral ailments. In dentistry, apart from reducing pain and force of grinding, Botox treats bruxism and improves the quality of life for its users.[18] Additionally, lip abnormalities and “black triangles,” difficult cosmetic issues with few effective treatment alternatives, can be treated with Botox.[17]

Dentists are seeing a surge in popularity because of the restorative and regenerative properties of dermal fillers and BTX, which were previously only possible with surgery. The fact that these operations restore a bright smile and enhance facial look is why they are growing in popularity. Those with gummy smiles, large masseters, and submandibular gland hypertrophy benefit from this therapy. Contraindications include immunocompromised individuals, neurological illnesses, pregnancy and breastfeeding, and anomalies of the neuromuscular system. Furthermore, BTX should not be administered to individuals who have keloidal scarring, active dermatoses, allergic reactions, motor weakness, body dysmorphic syndrome, or exaggerated expectations.[17,19]

Applications of BTX in dentistry

Temporomandibular joint disorders

The masticatory system is affected by temporomandibular disorder (TMD), which can lead to headaches, peri-auricular discomfort, neck pain, face pain, and reduced jaw excursion.[20] Myogenic components, bruxism-related muscle spasticity, external stresses, OMD, and psychomotor behaviors are common etiologic variables. Intraoral appliances, occlusal modifications, dental restorations, and surgery are examples of traditional therapies for TMD.[21] For most patients, however, these procedures are costly, intrusive, and permanent. BTA is an effective substitute for muscle relaxation as it lessens or eliminates the clenching reaction, which is often not enough to interfere with swallowing and chewing.[22]

Dentofacial esthetics

Botox and dermal fillers are used to provide volume to the lips and nasolabial folds, marionette lines, and other regions surrounding the mouth. Additionally, Botox can be utilized to fill up the interdental papilla and treat lip abnormalities, such as “black triangles.” Usually lasting 8 months or more, these treatments could need to be repeated if needed.[17]

Bruxism

According to Van Zandijcke and Marchau, who effectively treated a patient with severe bruxism with 100 U of BTA injections to the temporalis and masseter muscles, botulinum neurotoxin has demonstrated potential in treating bruxism symptoms. Studies show that BTA injections can reduce the frequency of bruxism episodes and decrease pain levels and maximum occlusal force generated by this pathology.[23]

Gummy smile

The “gummy smile,” or overabundance of gingival tissue in the maxilla when smiling, is a typical problem with dental hygiene and appearance. Over-contraction of the upper lip muscles, especially the levator labii superioris alaeque nasi, is frequently the cause of excessive gum exposure. Surgical techniques, such as Rubinstein and Kostianovsky, Miskinyar, or Rees and LaTrenta treatments, are not typically used to address gummy smiles.[24,25] Small, precisely titrated injections of BTX can prevent the top lip’s muscles from over-contracting, minimizing the exposure of the upper gums when smiling. It is advised to administer 3U at each injection location. Five patients who had hyperfunctional upper lip elevator muscles causing excessive gingival display were treated with Botox injections under electromyographic supervision in a small open-label experiment.[26] According to a study, smiling effectively increased upper lip length by 124.2% on average, and the benefit persisted for 3 to 6 months. The improvement must be repeated every 6 months to a year, though, because it is just temporary.[17]

Mandibular spasm

Mandibular spasm, in which the muscle responsible for shutting the mandible is still semicontracted, can impair oral hygiene, restrict dental treatment, make it difficult to open the mouth, make eating difficult, and reduce the usefulness of the mouth. Treatment with BTX can lessen the consequences of hypertonic or spastic muscles.[27]

Oromandibular dystonia

OMD is a movement condition that impairs mouth posture and function, resulting in problems, such as swallowing, eating, and speaking. It also causes involuntary spasms and muscular contractions.[28] Because it involves the masticatory apparatus, it is a subset of TMD. The majority of research on OMD comes from open-label trials, but all of them mention how well injections of BTX work. Tan and Jankovic’s greatest research revealed a 67.9% increase in speaking and chewing ability.[29]

Pathologic clenching

BTA has the ability to reduce muscular contraction, promoting the healing of injured tissue. Additionally, it can aid in preventing parafunctional clenching. By acting as a pharmacological splint, BTX eliminates the need for splints while the wound heals. In addition, it can shorten the duration of orthodontic treatment for those with deep bites or clenchers, which frequently need the use of fixed braces and removable retainers.[17] It may also be utilized as a medicinal splint in individuals who have just received a denture. In individuals who experience recurrent, chronic toothaches, it can also be utilized to confirm the source of discomfort.[28]

Statistics

The statistics of dentists practicing these methods vary across the world. An online questionnaire was devised and distributed via social media platforms to medical and dental students across the UK. Of the 146 comments that were received, 40% were from medical students and 60% were from dentistry students.[5] Of the 150 oral and maxillofacial practitioners from the United States who participated in another research, 42.7% reported using injectable treatments. Higher chances of having an injectable practice were linked to dual-degree training, further fellowship training, and didactic and practical continuing education training.[6]

Thai Dental Council has been awarding license or certificate to dentists who successfully complete qualifying examinations, which should institute official training programs on the application of BTX in dentistry.[30]

Some researchers strongly believe that in terms of esthetics, the dentist’s practice should not intersect with that of the physician. The areas of the anatomy and face structure that dentists can treat must be restricted for esthetic reasons.[30] Some authors are more concerned about people with body dysmorphic disorder (BDD), which is a prevalent condition among those who frequently visit dental practitioners, particularly those in cosmetic or esthetic practices. The increasing market for facial esthetics makes dentists more likely to encounter this patient group.[31] Safety is still another crucial issue. To bolster the notion that BTX may be utilized successfully in dental therapy, more studies have to be conducted.[15]

Limitations of the study

Lack of reporting the complications arising from such treatments might result in underprojection of the grave dangers of the situation discussed in the paper. While certain countries’ legal frameworks related to this aspect have been examined, many others have not been documented in scholarly works.

Recommendations

It is important to inform patients about the availability of BTX for dental usage and to make clear any potential risks so they may make an informed decision.[32] As dentists are more likely to subspecialize in esthetic dentistry, it is important to think about whether educating medical and dentistry students about NSFA would be engaging and helpful, and whether it would improve patient care, health services in general, and society at large.[5] Some authors have also recommended adding subjects, such as BTX in pharmacology, dermal fillers in materials science, and the aging face in anatomy progressively in the dental curricula.[32] Through the integration of NSFA sign-posting into undergraduate dental courses, we can guarantee that dentists embrace these subjects and understand the significance of patient safety.[32]

CONCLUSION

Dentistry students are becoming more interested in cosmetic treatments and are looking for postgraduate courses to educate them about the same. Cosmetic practice in dental education may be strengthened by combining topics, such as dermal fillers in materials science, BTX in pharmacology, and anatomy of the aging face in dentistry with emphasis on medicolegal laws, policies, and ethics involved. Students should have access to instructional media that walks them through these steps. Dental schools ought to promote their students’ exploration of these fields. A step toward enabling proper training and education routes and patient protection is a need of the hour.

Conflicts of interest

Nil.

Funding Statement

Nil.