Why You Can Get Botox at the Dentist and What That Says About Oral Healthcare Access in America
Adults Can Get Botox at Dental Practices in All 50 States, Yet Many Still Lack Access to Basic Dental Services
Winter 2021.
It was a moment of pandemic-fueled weakness. All of the Zooming had me fixated on my appearance. A friend had recently posted about getting Botox injections and I thought, why the hell not? So naturally, I asked my dentist to give me a quote.
Turns out, my dentist doesn’t do Botox, but he swiftly referred me to an oral surgeon in his office building who does. I didn’t wind up going through with it, but I have the oral surgeon’s number saved on my phone under the name “Andrew Botox” just in case.
Botox, best known for its anti-aging effects on the skin, is one of the most popular elective cosmetic procedures in the United States, with over seven million adults receiving some form of the “miracle poison” in 2019 for aesthetic purposes. Some may get their wrinkles injected away at a dermatologist’s or plastic surgeon’s office, but others opt to get it done at the dentist’s.
After all, as The Metropolitan Center for Complete Dentistry in East Hanover, NJ asks on its website: “While you’re investing in a beautiful smile, shouldn’t you make sure the rest of your face looks just as good?”
Today, with a bit of googling it is possible to find dental practices in all 50 states plus the District of Columbia that offer Botox to their patients, yet only 19 states offer comprehensive dental coverage for Medicaid-eligible (low-income) adults. Some states, like Maryland, will cover the cost of teeth pulling — but not the cost of vital replacements. 29 states only offer limited or emergency dental care, and 2 states, Alabama and Tennessee, offer no coverage at all. Under President Biden Congress had the opportunity to add basic dental benefits to Medicare Part B as part of Build Back Better, but the language was removed after intense lobbying from the ADA, mostly because of cost.
So while some Americans are able to leave their dentist’s office with a full-face transformation (having nothing to do with their actual teeth), others struggle to get in the door, even with painful or dangerous problems. And it’s emblematic of a broader problem with America’s oral health system, which financially rewards dentists who perform cosmetic procedures but offers little incentive for them to provide services to people without means. This leaves many who are economically or geographically disadvantaged no choice but to rely on free tooth extraction days or trips to the ER. Others simply go without dental care.
How Botox Arrived at the Dentist’s
In 2002 the FDA approved Botox© Cosmetic (made by the pharmaceutical company Allergan) for cosmetic usage. Prior to that, it was mainly used by ophthalmologists; the toxin’s first FDA-approved usage was to treat eye conditions.
After the 2002 FDA ruling, continuing education courses teaching medical professionals how to safely use Botox began popping up all over the country. Dentists, seeing the potential of the toxin both for cosmetic usage and as a tool for treating conditions like TMJ, started showing up to these courses, and by the late aughts, state dental boards were grappling with the question of if and under what circumstances Botox and dermal fillers should be administered by dentists.
In 2006, the Nevada Dental Board rejected a dentist’s request to use Botox for cosmetic purposes, arguing Botox for cosmetic purposes was “not in the scope of a practicing dentist.” The Kansas Dental Board similarly found in 2009 that “Using botox for anti-aging purposes is outside the scope of dentistry.”
Some dental boards, like New York’s, were a tad more vague with their recommendations. A 2008 guidance said dermal fillers and Botox could be administered by New York state dentists as long as they fell under the scope of “restoring and maintaining dental health.”
Dr. Louis Malcmacher, a dentist and the president of the American Academy of Facial Esthetics, wrote an article in the August 2009 issue of Dentaltown Magazine titled, “Dentists Doing Botox? It’s About Time!” in which he maintained that dentists are “the real facial specialists.”
He wrote: “We, as dentists, really have to start standing up for ourselves and realize how advanced our training has been in the oral and maxillofacial areas (that means the face from chin to forehead) compared to just about any other health-care professional who is allowed to deliver Botox and dermal fillers to patients. Dentists often challenge me that these procedures are best left to physicians. The question that you really have to ask yourself is, ‘Why?’”
By the mid-to-late 2010s, state dental boards began reversing course and recommending dentists be allowed to use Botox, with some reversing earlier stances. In 2015, Nevada’s dental board issued an updated guidance allowing less restricted use of Botox by dentists and declared dental hygienists eligible to do injections as well, as long as both the hygienist and supervising dentist have the proper certifications.
Dental practice websites offering the service describe the many benefits of Botox, from the ability to fix a “gummy smile” to soothing migraine headaches to easing the pain of lock-jaw or TMJ/TMD. While some dentists lean more heavily toward the therapeutic uses in their advertising, others focus on Botox’s ability to provide “natural-looking wrinkle reduction to refresh and renew your skin” and “create harmony between the soft tissues around your mouth and your beautifully restored teeth.”
An Industry Focused on Eternal Youth Leaves the Elderly and Disabled Behind
Dr. Kavita Ahluwalia (MPH, DDS), is a public health researcher and consultant who was most recently the director of Columbia’s postdoctoral program in Dental Public Health. She notes that the growing prevalence of cosmetic dentistry highlights the disparity in a healthcare system in which “dental is always optional.”
“There’s a huge amount of disparity,” Dr. Ahluwalia says. “It’s by race, ethnicity, and income, but also by age and ability to function.”
While it’s now possible for many dentists to openly perform Botox injections for the purposes of anti-aging, senior citizens in the United States are often left behind when it comes to accessing basic dental services.
Basic Medicare, which provides insurance for seniors and younger adults with disabilities, does not cover preventive dental services, despite the government’s own admission that many seniors — highly prone to oral health issues because of their age — lose their dental coverage upon retirement. An analysis by the Kaiser Family Foundation found that in 2019, about half of people on Medicare (24 million people) did not have dental coverage, with roughly the same amount of beneficiaries going without any dental care that year.
Even if someone qualifies for dental care through Medicaid, the benefits aren’t usually enough, says Dr. Ahluwalia. She adds that under New York’s Medicaid dental coverage, dentures can only be replaced every six years. For many seniors, paying to replace their own dentures is financially impossible.
In her extensive work with seniors, especially those in group living situations, the effects of the neglect are palpable. “These people are sometimes walking around with abscesses and broken teeth,” she says.
Nearly 14% of senior citizens in the United States have lost all of their teeth. Poor oral health is painful, is linked to other health issues like diabetes, high blood pressure (which are also COVID-19 comorbidities), and cancer, creates difficulty with eating and communication and can even have psychological effects, Dr. Ahluwalia explains.
“We forget, older people still want to look nice,” she notes. “I can’t tell you how many older adults have a pair of dentures that doesn’t fit but will wear it anyway when they see their family for the holidays, when they know they will be photographed.”
But Dr. Ahluwalia believes we shouldn’t blame dentists for the lack of dental health policy in our country. Dental school is expensive, with students taking on an average of $292,169 to get their education, according to 2019 figures. In our current system, dentists can make much more money offering Botox, dermal fillers, and veneers than they can by getting reimbursed by Medicaid to do basic cleanings.
How the country’s dental schools train their students has to change, Dr. Ahluwalia maintains. “Dentists aren’t really trained to take care of older adults or people with disabilities,” she said.
Meanwhile, training other medical professionals in oral health could help fill some of the gaps left by dentists.“I believe that we should put certain things in the hands of physicians and nurses because dentists aren’t taking care of everybody,” she said. “There’s absolutely no reason a physician shouldn’t be able to look into the mouth and say, ‘something’s going on.’”
“It has to come from the heart.”
Jennifer Geiselhofer works in Denver, Colo., where as a hygienist, she is not required to practice under the supervision of a dentist. In 2015, after spending 16 years at a private suburban dental practice — the kind that offers paraffin hand waxes, tea, coffee, and customized Alexa playlists for patients — she founded Dental at Your Door. Now Geiselhofer mainly serves people in Denver’s homeless shelters.
As the name suggests, Geiselhofer brings dental care straight to the shelters. She personally cleans the teeth of four or five patients a day, spending an hour and a half to two hours per person.
Some patients Geiselhofer sees have gone without dental care for years — in some cases, decades. The people whose mouths are in the worst condition, she says, are those who have recently gotten out of prison. Most cite the inability to afford bus fare to a dental office as the reason for their lapse in care, some have mobility issues, and many express a fear of going to a traditional dentist setting.
The result of just one cleaning is powerful.
“Men in their 40s and 50s will literally cry after their appointment,” Geiselhofer. “They talk about wanting to get a job.”
For those patients who need to have follow-up work done by a dentist, Geiselhofer refers them to a good, quality practitioner who, like her organization, accepts Medicaid. But for people without an expert like Geiselhofer to guide them, just the act of finding a dentist who accepts Medicaid can be impossible.
Administering a couple of shots of Botox to a patient can earn a dentist hundreds of out-of-pocket dollars in a matter of minutes. Working with patients who are low-income can be less desirable for dentists, and for a variety of reasons.
“It is really about the reimbursement. That’s really what it boils down to,” says Tameka Schley Lee (RDH, BSDH), a dental hygienist and the secretary of the Georgia Dental Hygienists’ Association.
The ADA reports that as of 2019, 43% of dentists nationwide accept Medicaid or CHIP, the Children’s Health Insurance Plan. However, ADA data for the same year indicates that reimbursements from government programs only accounted for 7.6% of dentists’ billing sources.
Medicaid typically only reimburses dentists for about half of their requested fees. But there are other reasons why dentists are not willing to accept Medicaid: red tape, missed appointments, and, in their words, “unreliable” and “ungrateful” patients.
Whereas some dentists see Medicaid patients as unreliable, Lee sees systemic barriers to care. There are transportation issues, childcare issues, and employment issues that make it difficult for people to keep their appointments.
Lee herself did not have her first dental visit until the age of 19. Her own access issues were part of what drove her to pursue a career in dental healthcare. “I didn’t like my smile growing up,” she says.
She is currently in graduate school, working toward a master’s degree in public administration with an emphasis on healthcare management. She’s the founder of Empower, RDH, which provides mentorship and coaching to dental hygiene clinicians. Soon, she’ll be launching a podcast called Truth Scalers.
Lee works as a care coordinator for one of Georgia’s managed care (Medicaid) dental plans. Part of her job is working with current dentists in the network and another part is recruiting new dental providers. She admits that there is a high no-show rate for this population of patients, but without empathy from dentists, many patients will continue to put off treatment until it’s too late, resulting in serious, life-threatening health issues and driving up healthcare costs for everyone.
“It has to come from the heart,” Lee says. “Where the dentist says, ‘I know what comes along with this and I’m willing to help.’”