The Wrinkles That Botox Causes for Dentists: Case Study and Unique Risks

This article was originally printed in our Second Quarter 2023 issue of The Scope: Dental Edition. Read more from the publication here.

For dentists, Botox can cause wrinkles. Here’s a case study involving the use of Botox in dentistry and a deep dive into the unique risks that Botox can pose for dental professionals. To learn more about the history of Botox in dentistry, read this recent article on our blog.

Case Study: Dazed and Confused

A 52-year-old female plaintiff with a history of bruxism underwent placement of a five-unit bridge in the upper-right portion of her mouth, as well as the placement of two upper anterior implants, six lower anterior veneers and crownwork. The plaintiff, who was an admitted Botox user, received Botox injections to her jaw muscles and around her eyes during her dental work.

The plaintiff alleged that the dental work was negligently performed and she needed to have all the restorations removed, root canals performed, new implants placed and a replacement bridge made by a subsequent treating dentist.

Regarding Botox, the plaintiff alleged that she was “heavily drugged” for the dental procedures when the defendant dentist discussed using Botox around her eyes and, therefore, she did not, and could not, consent to its use. The plaintiff woke up to realize that Botox had been injected between her eyebrows without her consent.

She further testified months later that the dentist told her that “he would like to administer Botox injections while she was in a groggy state.” Although it was clearly self-serving testimony, the dentist’s documentation regarding the dental indications for the use of Botox and consent discussion was poor. Importantly, the plaintiff also alleged that the use of Botox around her eyes was outside the scope of dentistry. 

An expert review was critical of the treatment, including that there was no appropriate documentation of the plaintiff’s periodontal condition and care, and there were no notations within the chart advising the plaintiff that much of the treatment was not ideal and that she was proceeding at her own risk. The expert also commented unfavorably on the lack of documentation regarding the dental indications for the use of Botox and the related consent issue.

Similarly, imaging studies and documentation by the plaintiff’s subsequent treating dentist showed unacceptable margins around most teeth and improper crown lengths. Additionally, the lack of a bite guard had resulted in dislodged veneers. These objective findings were unfavorable to the defendant dentist and, ultimately, the lawsuit was resolved in favor of the plaintiff.

This case study highlights several Botox-related risk factors for dentists, including informed consent and whether its use is within the scope of dentistry. The specific lesson here is that there can be no informed consent discussion when a patient is “dazed and confused.”

The Unique Risks Associated with the Use of Botox in Dentistry

As a matter of caution, dentists using Botox as part of their treatment plan should ensure that it is related to the restoration and/or maintenance of dental health and document such in the dental record. Similarly, dentists should ensure that they, or the dental provider using it in their office, have the requisite training to use Botox in patient care.

The need for requisite training highlights another risk of using Botox in the dental office: dental malpractice. There are several areas of increased risk related to malpractice for dentists who use Botox that include competence, supervision and informed consent.

Competence

The dentist, or person under their supervision, should be trained in the storage, preparation, dosage and use of Botox through an accredited course. For example, the user should be aware of the lethal, maximum recommended and proper therapeutic dosages for patients. The user should also be aware of the side effects and contraindications of Botox.

Supervision/Vicarious Liability

New York State law permits “licensed medical professionals” such as RNs and LPNs to inject Botox under the supervision of a physician or dentist. Non-licensed individuals may not inject Botox, even with supervision. A dentist can face malpractice liability based upon an allegation of failing to adequately supervise or permitting an unlicensed individual to perform a Botox injection. In addition, under the doctrine of “vicarious liability,” one person may be held liable for the acts of another person. Therefore, in the dental setting, a dentist may be vicariously liable for anyone permitted to perform Botox injections in their office, and this type of liability may not be covered by your malpractice policy.

Informed Consent

The use of Botox in the restoration or maintenance of dental treatment requires a detailed informed consent discussion about the material risks, benefits and alternatives, including not using it as part of the treatment plan. In addition, the dentist should inform the patient that Botox is not FDA approved for specific uses in dentistry and explain its “accepted” uses in dentistry. It is important to discuss and emphasize that there are no guarantees related to the use of Botox, especially for aesthetic results.

The dentist should be familiar with the information on the package insert including, but not limited to, storage, dosage, use, contraindications, warnings, side effects and adverse reactions.

Possible side effects when used in conjunction with antibiotics are commonly overlooked as part of the informed consent discussion. Some antibiotics, including gentamycin, amikacin, tobramycin and neomycin, may exaggerate the effects of Botox.

Fortunately, adverse reactions to Botox are localized and uncommon. Side effects may include a temporary change in facial expression, allergic reactions, rash, itching, headache, neck or back pain, muscle stiffness, difficulty swallowing or shortness of breath. However, when a facial injury related to the use of Botox is permanent, it can result in a significant liability award. As noted below, if the use of Botox is outside the definition of dentistry, there is an additional risk that it will fall outside of professional liability coverage.

Finally, the dentist should use their best professional judgment in deciding what is part of the informed consent discussion, and it is vital to document the discussion in the dental record. It is recommended that a separate note be made independent of any pre-made electronic or paper consent form.

Lesser-Known Additional Risks to Consider When Using Botox

Breach of Contract and Advertising Liability

In addition to malpractice and professional misconduct allegations, dentists may also face breach of contract allegations. More specifically, a patient may be dissatisfied that they did not obtain relief from TMJ pain, that they still have a gummy smile or that wrinkles around the mouth are still visible. As part of the treatment plan and informed consent discussion, the dentist should manage expectations regarding the results of the Botox treatment and ensure that the patient understands that there are no guarantees to achieve a specific result.

Similarly, dentists who advertise Botox treatment as part of their practice (or as available in their office by another vendor) using websites, advertisements and/or social media must comply with New York State truth-in-advertising laws.

Professional Liability Insurance Coverage Issues Related to Botox Use

Allegations related to the use of Botox may fall outside the scope of professional liability insurance coverage. Some of these types of allegations include using Botox outside the definition of dentistry and inappropriate guarantees made to patients. When there are Botox allegations that fall outside the scope of professional liability coverage, a dentist’s personal assets could be exposed and they could be responsible for a monetary payment related to those allegations.

For these reasons, dentists should be certain that their use of Botox is within the definition of dentistry and that no guarantees are made regarding the outcome from its use. In addition, dentists should review their professional liability insurance policy to determine whether their current use of Botox falls outside of the policy’s coverage.

Botox: The Verdict for Dentists

The use of Botox in dentistry provides the benefits of increased treatment modalities for patients and the possibility of a competitive edge. While attractive, these potential benefits should be viewed in the context of the additional unique risks dentists face when using Botox.

Caution must be taken to ensure that the use of Botox is within the definition of dentistry. Similarly, dentists must ensure that they, or the licensed professional performing the injections, have the competence and experience to perform the treatment.

Additional attention should be given to ensure that an appropriate informed consent discussion takes place before treatment and that it is documented in the dental record. Patient expectations as to the results of Botox treatment need to be managed with an emphasis on dispelling any notion that there are guaranteed results.

Finally, dentists should be aware that certain uses of Botox that do not fall within the definition of the practice of dentistry may fall outside of professional liability insurance coverage.

Got questions about Botox in dentistry? Policyholders can contact our team of risk management professionals 24/7 at no additional cost by calling (844) 667-5291 or emailing hotline@tmglawny.com. For more resources for dentists, visit the MLMIC Dental blog, The Scope: Dental Edition, Dental Impressions and our Twitter and LinkedIn pages.