Are Dermal Fillers Dentistry?

The rise in demand

Recent social media influence has set up a world of aesthetic idealism, whereby rises in demand for non-surgical cosmetic treatment to cater for the unrealistic desire of ‘perfection’ has meant that the industry, worth approximately £2.75 billion in the UK,⁸ has gained interest among dental practitioners. The Department of Health report by Sir Bruce Keogh stated that ‘dermal fillers are a crisis waiting to happen’, ⁹ namely due to the fact that the industry remains unregulated, with fillers not being supplied as a prescription-only medicine in the UK,¹⁰ despite alarming risks of disfigurement, vascular occlusion and subsequent necrosis as potential sequelae.¹¹ According to the GDC, dental professionals who chose to engage in courses to enable the administration of injectable fillers must be able to ‘back up the decisions’ made and have appropriate indemnity cover for these procedures.¹² However, this discussion regarding fillers poses the question of whether regulated professionals should be carrying out un-regulated procedures.

Dentistry in conjunction with dermal fillers

Many dental registrants routinely carry out elective aesthetic dentistry in the form of whitening, veneers and composite bonding to enhance the perceived aesthetics of a smile. Unlike non-surgical aesthetics, carrying out procedures designed to improve the aesthetic appearance of teeth amounts to the practice of dentistry and is therefore limited to GDC registrants.¹² Among the primary skills listed by the GDC scope of practice (Table 1), further training in non-surgical cosmetic treatment can also be provided as an additional skill after graduation.¹³ As well as intra-oral treatment, dental professionals have a plethora of knowledge in carrying out an extra-oral examination by assessing skeletal discrepancy, lip competency and facial symmetry, and thus, may be able to use these transferable skills to provide holistic treatment in facial aesthetics. For example, a patient may present with a loss of facial height secondary to severe tooth wear.¹⁴ In this case, injectable fillers may assist in reshaping the lower face to improve facial proportions.¹⁵ The advantage of this being carried out by dental practitioners is that, in conjunction with aesthetic treatment, the root cause of this loss in vertical tooth height can be appropriately addressed, monitored and managed in accordance with Delivering Better Oral Health guidelines.¹⁶

Additionally, dentists are trained to have an in-depth understanding of head and neck anatomy, including nerve and vascular supply to facial structures. As a result, this could potentially enhance prevention and management of complications. For instance, it is common knowledge to aspirate prior to the administration of local anaesthetic in the delivery of an inferior alveolar nerve block to prevent intravascular injection,¹⁷ and the same principle is applied to the delivery of dermal fillers because the risk of skin necrosis is reduced by aspirating as a prophylactic measure.¹⁸ Similarly, management of medical emergencies, for example anaphylaxis,¹⁹ is well instilled in undergraduate training, therefore, dentists are well placed to manage such adverse reactions. Furthermore, dental practitioners are required to act in accordance with infection control policies to ensure patients are treated in a hygienic and safe environment,¹² thus aseptic conditions are provided to patients when choosing to have this treatment carried out by dentists, minimizing the risk of cross-infection.

Proceed with caution

Before engaging in dermal filler treatments, the clinician should be aware of the associated potential risks. In particular, while carrying out procedures such as non-surgical rhinoplasty, whereby injections into high-risk facial zones (namely the glabella, nasal ala and dorsum of the nose¹¹) may result in stroke and permanent blindness.²⁰ Vascular occlusion occurs as a result of intravascular injection or compression of a blood vessel by surrounding filler.²¹ The importance of early recognition, for example, by assessing capillary refill time, whereby a delayed response of more than 3 seconds may be indicative of vascular compromise,²⁰ is paramount in ensuring we are safe practitioners. The immediate use of hyaluronidase, which acts to dissolve excessive quantities of injected filler,²² may be useful in mitigating some of the adverse effects of hyaluronic acid.⁹ At present, hyaluronidase is unlicensed for reversal of complications associated with dermal filler; however, the Medicines and Healthcare Regulatory Agency (MHRA) acknowledges that its use is permitted, provided the patient's best interest is respected.²³ As dental professionals, we must uphold a duty of care, and inadequate training poses a threat to our patients. Therefore, it is of utmost importance that thorough training is prioritized, which focuses on knowing arterial depth and managing complications appropriately. An additional consideration is the use of ultrasound imaging, which could enable the clinician to carry out ‘anatomical mapping’ and thus improve the safety of treatment.²⁴

Regulation and medico-legal implications

Avoiding the causation of harm, that is non-maleficence, is one of the major ethical pillars in healthcare. As such, a dental practitioner may be subject to investigation by the GDC for professional misconduct if patient safety is endangered, or performance puts patients at risk.²⁵ Therefore, to reduce the risk of unwanted complications, the priority should be placed on rigorous education and training courses before commencing non-surgical aesthetic treatment.

One attempt at regulating the provision of dermal fillers has been the establishment of the Joint Council for Cosmetic Practitioners (JCCP).²⁶ The JCCP has formulated a register of ‘approved education and training providers’ that meet the standards set by the Cosmetic Practice Standards Authority (CPSA),²⁷ which in turn enables the practitioner to be better informed when choosing training programmes. Furthermore, the JCCP has a ‘memorandum of understanding’ with the GDC, which intends that their working relationship will promote patient safety and public protection in the non-surgical treatment sector.²⁸

From a medico-legal perspective, the premises in which non-surgical cosmetic treatment is practised should be taken into consideration. For example, the GDC's Standards for the Dental Team state that guidance on medical emergencies must be followed, as per the UK Resuscitation Council.²⁹ Consequently, this means that all clinical dental areas should have immediate access to resuscitation equipment, including suction and an automated external defibrillator (AED).³⁰ Thus, if these are absent from an aesthetic clinic, serious concerns about the dental professional may be brought to the attention of the GDC, and potential action against the registrant may unfold.

Prior to offering enhancement procedures, it is essential to check current indemnity arrangements and if they are not covered, whether second insurance may be required. At present, the Dental Defence Union (DDU) does not provide indemnity for work undertaken outside the dental surgery setting, thus, alternative indemnity would be required if treatment were to be provided in an aesthetic clinic.²⁴ Furthermore, current indemnity providers may have restrictions on the facial areas covered. BDA indemnity covers botulinum toxin, whitening and fillers ‘above the lower border of the mandible’,³¹ and therefore, fillers into the neck or elsewhere would warrant a second provider.

The role of the Care Quality Commission is to monitor and regulate services to ensure that they meet fundamental standards of quality and safety. Currently, the CQC does not regulate surgical procedures involving ‘subcutaneous injections to enhance appearance’.³² However, prior to embarking on such treatment, a dental practitioner must carry out diagnostic and screening procedures to formulate a treatment plan, which is a regulated activity by the CQC. Therefore, one could argue that the provision of dermal fillers is indirectly regulated when carried out by a dental clinician, resulting in an overall improvement in the quality of care to patients.

Changes to the law in non-surgical aesthetic treatment

Another commonly used procedure to enhance facial aesthetics is the provision of botulinum toxin (Botox), which works by blocking the release of acetylcholine, thus inducing temporary paralysis of facial muscles.³³ Unlike dermal fillers, it is administered as a prescription-only medication (POM). This means that under Section 58(2) of the Medicines Act,³⁴ only registered medical and dental professionals are able to prescribe, dispense or administer these medications.³⁵ Consequently, dental hygienists/therapists can only provide muscle relaxing injections to patients following an initial face-to-face consultation with a dentist, provided they are fully trained, indemnified and competent to do so.³⁶

The Botulinum Toxin and Cosmetic Fillers (Children) Act came into effect on 1 October 2021,³⁷ and aims to safeguard children from the potential health risks associated with these procedures. The new law states that it is a criminal offence to administer dermal fillers or Botox to an individual under 18 years of age, except under the direction of a registered medical practitioner in cases where there is a clinical need. Failure to comply with these regulations could result in a criminal prosecution and an unlimited fine.38 While dermal fillers are mainly indicated in an aesthetic context, Botox also demonstrates medicinal uses, and this may justify its use in those under 18. Examples include alleviating pain associated with temporomandibular joint disorder (TMD) via the relaxation of the masseter and temporalis muscle,³⁹ as well as prophylaxis for migraine headaches, in patients who have not responded to conventional pharmacological therapies.⁴⁰ As a result, dental professionals are in a good position to provide these treatments, owing to their prior education on facial pain and its appropriate management strategies. However, as with dermal fillers, undesirable outcomes may arise with the use of Botox. Thus, detailed knowledge of musculature depth is required to avoid complications, such as eyelid ptosis and facial asymmetry with use of the neurotoxin.⁴¹ As per the Montgomery vs Lanarkshire Health Board case,⁴² the material risks of all non-surgical cosmetic procedures should be discussed with the particular patient, taking into account their own specific needs and expectations, as well as any suitable alternatives, so that informed consent is obtained prior to treatment.

Conclusion

Initially, it may be tempting to embark on courses to administer aesthetic injectables, especially where there has been a substantial demand for facial aesthetic treatment. From a patient perspective, being treated by a dental professional as opposed to a non-medical professional may offer advantages owing to a professional's ability to apply prior knowledge of anatomy, use of sterile environments and a better overall awareness of facial aesthetics. However, a greater emphasis should perhaps be placed on psychological assessment⁴³ of patients, to ensure that care is provided in a holistic manner. Further consideration into whether expectations of treatment are realistic and achievable is also important to avoid possible medico-legal issues in the long run. A potential worry is that clinicians may rush to start these courses, soon after the completion of their undergraduate degree, which may mean that insufficient time has been spent to refine basic dental skills, including patient management. Therefore, it may be wise to focus on enhancing core dental skills before career advancement into the world of aesthetics.

In the authors' opinion, fillers and the use of Botox fall within the practice of dentistry and should be performed by trained and experienced registrants with appropriate indemnity and skill set to not only manage the procedure, but to allow full informed consent, cognizant of the range of significant complications regularly reported in dental journals.^44,45