Face forward: Growing number of dentists offering Botox and fillers

Responding to client demand, more and more dental clinics are adding Botox and fillers to their list of offerings, writes Helen O’Callaghan

IF you haven’t already seen it, next time you’re in your dentist’s waiting room you might spot, prominently displayed, a copy of the Dental Council’s code of practice for non-surgical cosmetic procedures. That’s if your dentist is one of the many in Ireland now offering Botox and dermal fillers.

Botox is by far the most commonly sought non-surgical cosmetic procedure in the US, where the market for both it and dermal fillers is hugely expanding — and the British market for these treatments is also expanding rapidly, says Dr Liz Kelleher, a dentist and aesthetics practitioner in Passage West, Cork. “Within both the US and UK, dentists are involved in supplying these treatments. Trend-wise, Ireland tends to follow these [regions] and because of social media it’s happening faster now than ever before.”

Kelleher says patient demand in Ireland for such treatments from dentists is growing exponentially. However, no register is kept regarding how many dentists here are providing Botox/fillers. “Anecdotally, we’ve spoken to dentists who are being asked by their patients for it, and they send them on to us. Also, dentists have got involved due to patient pressure and demand. The younger ones especially are starting to get involved in [providing] Botox.”

Dr Brenda Barrett, owner and clinical director of Carlow-based Pembroke Dental and Pembroke Dermal, has seen “steady and increasing demand” for “injectables” — Botox and dermal fillers — over the last five years.

In March 2013, the Dental Council published its code of practice relating to non-surgical cosmetic procedures. It states that the ‘use of botulinum toxins [Botox is a brand name] and dermal fillers for cosmetic treatments is not the practice of dentistry’.

Is the Council in danger of being out of step with patients? Kelleher says its function is to protect the public. “It moves slowly and very thoughtfully in how it gives advice to dentists on how to practice.”

Nevertheless, she feels the Council is out of step with where the public is at.

“Patients are reading about Botox and fillers. They’re seeing it on reality TV. They know dentists are doing these in other countries so they’re asking their own dentists about it.”

In Ireland, the Dental Council’s general function is to promote high standards of professional education and professional conduct among dentists. A spokesperson for the Council says it isn’t trying to stop dentists providing these procedures. “The Dental Council isn’t against dentists providing botulinum toxins.”

The key issue, he says, is the practice of dentistry and what the patient expects when they walk into the dentist’s. “If a patient walks in and their dentist is now offering non-surgical cosmetic procedures, it’s natural for the patient to think this is now the practice of dentistry.”

Explaining that the main purpose of the code is for “patient information and patient safety”, he says the clinical training to provide non-surgical cosmetic procedures is not part of the undergraduate dental curriculum. “If you’re looking at a newly minted dentist walking out of the dental school in Cork or Dublin, they’re not trained in providing non-surgical cosmetic procedures to patients. The purpose of the code is to put a little bit of clear blue water between the practice of dentistry and the provision of non-surgical cosmetic procedures,” he says, adding that dentists wishing to provide non-surgical cosmetic procedures must do additional training.

While at first glance dentists may be seen as primarily preoccupied with tooth and oral health, their brief has for centuries extended beyond this. “For hundreds of years, we’ve had a role in making people look better,” says Dr Kieran O’Connor, Irish Dental Association president and a dentist in general practice in Youghal.

“Long before the advent of modern dentistry, for over 200 years, dentures have been made. For someone with no teeth, dentures make a huge difference to the face.”

O’Connor points out that when dentists straighten teeth and whiten them, they’re improving people’s smile. “We’re dealing with cosmetics and aesthetics all the time. It’s so important to people’s sense of self-esteem. We’re not just treating mouths, we’re treating people.”

Kelleher also points to conversations about people’s appearance being part of dentists’ remit. “How the teeth support the lips, if teeth are too far out or too far back, it all affects appearance. When we make dentures for older patients, we’re supporting the musculature of the lips. Logically speaking, fillers can be used in the same areas to help support the muscles around the lips.

“And Botox is used for people who have problems with their jaw joint and who have a high smile line — the upper lip is pulled very taut and you can see a lot of gum. People don’t like that look — by using Botox, you can avoid a person having to have gum surgery for the sake of appearance.”

Kelleher points out that dentists have extensive training in the anatomy of the head and neck and long experience of providing care in the head and neck region, so providing non-surgical cosmetic procedures is a natural extension of these skills.

“Dentists are analysing faces all the time. They understand aesthetics of teeth and of the mouth. It’s a natural progression to go onto analysis of the face, to look at the balance of the face and how age has affected that balance,” says Kelleher.

She says dentists are trained from their primary degree to look at the patient, at how they express themselves, how they move; for example, do they show their teeth?

“People who don’t like the look of their teeth will talk to you without revealing them. We’re trained to look at how patients move certain parts of their faces and so we can see what treatments might benefit them.”

At Pembroke Dental and Pembroke Dermal, Barrett says the general public’s curious about Botox, fillers, and facial aesthetics across the board. “People are talking about its effectiveness and what it can do for ladies of a certain age and younger.” She says 99% of her clientele are women, though she has done treatments on men. “One man came because he thought he was getting very ‘aged-looking’. He was going for a big promotion and thought he might get passed over.”

The majority of clients are women in their 40s, though those in their late 20s and early 30s come too, chiefly for Botox. “They’re young mothers with big stressed lives, who are chasing themselves all the time. They say they look cross all the time. Botox makes you look ‘a lot less’ — a lot less old, stressed, or tired. It relaxes your face,” claims Barrett, who also treats secondary school teachers who’ve had very personal, pointed remarks made to them by students.

“Lips start to thin as we age and teachers get students saying ‘Miss are you in mean humour today?’”

Botox and fillers are equally popular among Kelleher’s facial aesthetics patients, who age-wise are evenly split between 30s, 40s and 50s. “Some come in their late 30s, others in their early 30s depending on how particular they are.

“Very few come in their 20s — they might come for under-eye treatment if they feel very hollowed-out genetically or for lip augmentation, which is a product of selfies and the Kardashians. Social media really pushes the plumped lip look. A gummy smile would bring them in their 20s too.”

She says women in their 30s and 40s want to ease signs of ageing: Frown lines, lines at side of eyes, flattening of cheeks leading to nasal-labial lines, and jowls.

About 15% of her patients are men, mainly mid-30s to early 40s. When she asked one man recently what prompted him to come, he said his girlfriend told him he needed to “do something about his forehead lines”.

Botox costs €250 approximately and for younger patients in their 30s can last up to six months — three to four months is more usual for 30- and 40-somethings.

“It’s down to how the individual metabolises it,” says Kelleher, adding that as it wears off, people go back to how they looked pre-treatment. “You’re giving that bit of skin a rest for up to six months so your skin won’t be as lined 10 years down the road if you’ve been having it done regularly.”

Dermal fillers start at €350 and duration of stay depends on where on the face you’ve had them — cheeks generally last for 12 months versus six months for lips.

Dentists might be a good fit for providing non-surgical cosmetic procedures, but why do patients themselves opt to get these treatments from someone who’d more usually be discussing fillings with them rather than fillers?

Historically, Botox and dermal fillers were delivered in beauticians’ practices or at the back of a hairdresser’s where the practitioner came once a month. “They could be anywhere,” says Kelleher. “Whereas if you’re going to your dentist, you know them, their approach, and technique; you already trust them, so it’s a comfortable place to ask, is this for me? What will this do for me?”

And at a very basic but crucial level, patients are used to dentists giving injections so they know they can give a pain-free local anaesthetic well. “Dentists are used to giving fine controlled injections in the face,” says Kelleher.

Barrett says patients can depend on a sterile environment at the dentist’s. This plus the fact that dentists are medically-trained professionals, as well as patients’ belief in the practitioner’s trustworthiness and honesty are big factors. “I turn away a lot of people and tell them facial aesthetics won’t work for them — for example, if they have pronounced bags above or below the eyes that would require surgery rather than Botox or fillers.”

Kelleher too says it’s a plus for patients that dentists know about body dysmorphia. “You need to be able to assess a patient psychologically to know whether or not they’re in a good place to have an aesthetic treatment done.”

A wish to be discreet is also behind some people’s decision to choose the dentist when they want a bit of Botox. Barrett finds many women hide it from their partners. “It’s very handy to be able to say ‘I’ve got a dental appointment’. It’s easier to say to the kids too.”

“If somebody they know is in the waiting room when they come out, well they could have been in for dental treatment,” says Kelleher. There’s an element of being proud of the fact that ‘I look good without help’.”

Kelleher finds not wanting others to know was a bigger deal five years ago. “Our business growth now is through word of mouth so people are talking about it. It’s across the media so people are talking about what they’re getting done.”

Whatever about patients’ wishes for discretion, the Dental Council is adamant that dentists providing non-surgical cosmetic procedures display a copy of the council’s code of practice prominently in their practice. It must be situated in a place where the patient could reasonably be expected to see it before treatment. It states ‘you must only provide these treatments if you have undertaken additional education and training, and attained the necessary competence’. However, the Dental Council doesn’t approve, accredit, or have any input into courses on non-surgical cosmetic procedures.

Kelleher has done a two-year master’s in aesthetic medicine in London and says training is vital. With Britain bringing in stringent regulations in relation to aesthetic practitioners, she’s hoping Ireland will follow.

“It needs to be regulated properly. Any of the dentists I talk to [who provide these treatments] have done extensive training. Have all dentists done it? I don’t know. There’s no compulsion for us to do it. It’s down to our own ethics.”

The code of practice also stipulates that dentists doing these procedures “must have appropriate indemnity insurance cover”. And the promotion/marketing of these treatments must be distinct and separate to the promotion/marketing of their practice as a dentist — “for example, this will entail maintaining separate websites, placing separate advertisements, and having separate practice brochures, posters, etc”.

Kelleher “agrees wholeheartedly” with this. “You have separate businesses — I am LK Aesthetics and Mint Dental. Patients shouldn’t feel hard-sold to.”

Some suggest the recession and severe cuts in State dental schemes pushed dentists towards offering cosmetic treatments like Botox and fillers.

Absolutely not, says Kelleher. “It has been a natural evolution. We are now riding the wave of what has been happening in the US and the UK. And dentists are well placed to do these treatments successfully and in an ethical manner.”

From tooth-fixer to smile-enhancer to youth-restorer, it’s arguable that no profession has itself had such a makeover in recent decades as dentists have had.

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