Why Does Michigan Take an Antiquated Position on Fillers and Botox in Dentistry?

In Michigan, is it permissible for a general dentist to perform Botox and filler injections? And may he/she delegate this function to a dental hygienist?

With respect to the issue of Botox and other fillers, the Michigan Board of Dentistry (the Board), in a February 29, 2011, statement, stated that “general dentists may not use Botox, dermal fillers or any other neurotoxin for cosmetic purposes.”

In March 2012, the Board attempted to justify its position by narrowly defining the practice of dentistry to be the treatment of teeth: “[T]reat areas of the face that are reasonably identified as dependent tissue of the teeth.” (Emphasis added.)

The Board understands the medical use in dentistry for Botox and dermal fillers for TMJ, bruxism (teeth grinding), trigeminal neuralgia, and other conditions. However, the Board stated its concern about the consequences of the improper administration of Botox and dermal fillers.

In 2011, the Board took the position that “dentists who do not undergo proper training, or who are practicing outside their scope of practice are placing patients at risk.” This statement specifically addresses general dentistry in stating that “the general practice of dentistry does not include injections of these substances for cosmetic purposes.”

The Answer to Fillers and Botox in Dentistry is Not Very Clear

In essence, the Board has empowered itself to self-regulate general dentists in Michigan and limit the ability of dentists to use fillers and Botox in dentistry. The restrictions are not clear and depend on whether the dentist has the training. Therefore, the determination of whether a dentist can perform Botox and other filler injections is not easily understood.

The Board clarified — or muddied the waters — its position when answering several questions posed by members of the dental community.

One asked: “[A]ccording to the Board’s 2012 Botox Statement, specifically who can and who cannot administer Botox and dermal fillers in dentistry? Which specialists? Which general dentist?”

The Board’s answer: “[A]ny dentist treating painful or debilitating conditions in the oral region (as defined in the Statement) with the proper level of training (which needs to remain undefined.)” Further, “according to the 2012 Board of Dentistry Botox Statement[,] the usage of these products for purely cosmetic reasons is not within the scope of practice for general dentist.” (Emphasis added.)

What Does ‘Dentistry’ Actually Mean?

However, the Board’s 2011 statement and 2012 explanation do not properly define “dentistry.”

MCL 333.16601(d) defines dentistry as “the diagnosis, treatment, prescription, or operation for a disease, pain, deformity, deficiency, injury, or physical condition of human tooth, teeth, alveolar process, gums or jaws, or their dependent tissue, or an offer, undertaking, attempt to do, or holding oneself out as able to do any of these acts.”

The statute was modified March 27, 2019, but the definition of “practice of dentistry” was not amended. When the Board in the 2011 and 2012 statements limited the practice of dentistry to “areas of the face that are reasonably identified as dependent tissue of the teeth” (emphasis added), it narrowed the statutory definition of dental practice, which is limited to “… disease, pain, deformity, deficiency, injury, or physical condition of human tooth, teeth, alveolar process, gums or jaws, or their dependent tissue …” (Emphasis added.)

The Board does not have the authority to amend a statute.

Botox in Dentistry: ‘An Important Place in the Field’

An article written in Today’s RDH stated: “Dentistry is poised to be the next medical specialty to offer Botox treatments, and it might just prove to have an important place in the field. Let’s move past the controversy and show that it is appropriate to have Botox treatments administered in a dental office.”

A reasonable conclusion relating to the use of Botox by a general dentist in Michigan is as follows:

    1. Without sufficient training, the use of Botox by a general dentist is generally prohibited.
    2. The use of cosmetic Botox by a general dentist without sufficient training is generally prohibited.
    3. The use of Botox to “treat a disease, pain, deficiency, injury, or physical condition of the human tooth, teeth, alveolar process, gums or jaws or their dependent tissue, or an offer, undertaking, attempt to do so,” is within the practice of a dentist if he/she has the specialized training necessary to perform these acts. (Emphasis added.)

What About Dental Hygienists?

With respect to a dental hygienist, the Board is very clear: “‘Practice as a dental hygienist’ means practice at the assignment of a dentist in the specific area of dentistry based on specialized knowledge, formal education, and skill with particular emphasis on preventive services and oral health education.”

MCL 333.16611 states:

“(4) Upon delegation by a dentist under section 16215 and under the direct supervision of a dentist [emphasis added], a dental hygienist may administer intraoral block and infiltration anesthesia or nitrous oxide analgesia, or both, to a patient 18 years of age or older, if the following criteria are met:

(a) The dental hygienist has successfully completed a course in the administration of local anesthesia or nitrous oxide analgesia, or both, as applicable, offered by a dental or dental hygiene program accredited by the commission on dental accreditation of the American dental association and approved by the department. A course described in this subdivision involving local anesthesia administration must contain a minimum of 15 hours didactic instruction and 14 hours of clinical experience. A course described in this subdivision involving nitrous oxide analgesia administration must contain a minimum of 4 hours of didactic instruction and 4 hours of clinical experience. The courses of instruction shall include content in all of the following:

(i) In the case of local anesthesia, the following:

(A) Theory of pain control.

(B) Selection of pain control modalities.

(C) Anatomy.

(D) Neurophysiology.

(E) Pharmacology of local anesthetics.

(F) Pharmacology of vasoconstrictors.

(G) Psychological aspects of pain control.

(H) Systemic complications.

(I) Techniques of maxillary anesthesia.

(J) Techniques of mandibular anesthesia.

(K) Infection control.

(L) Local anesthesia medical emergencies.

(ii) In the case of nitrous oxide analgesia, the following:

(A) Nitrous oxide analgesia medical emergency techniques.

(B) Pharmacology of nitrous oxide.

(C) Nitrous oxide techniques.

(D) If such a course is available, selection of pain control modalities.

(b) The dental hygienist has successfully completed a state or regional board-administered written examination on either or both of the following within 18 months of completion of the course work required under subdivision (a):

(i) Local anesthesia.

(ii) Nitrous oxide analgesia, if such an examination is available and approved by the department.

(c) The dental hygienist maintains and can show evidence of current certification in basic or advanced cardiac life support in compliance with R 338.11701 of the Michigan administrative code.”

‘Direct Supervision,’ ‘General Supervision’ and ‘Monitoring’

MCL 333.16611(b) further states “direct supervision” as meaning that a dentist:

“(i) Designates a patient of record upon whom the procedures are to be performed and describes the procedures to be performed.

(ii) Examines the patient before prescribing the procedures to be performed and upon completion of the procedures.

(iii) Is physically present in the office at the time the procedures are being performed.”

In addition, “general supervision” means that the dentist:

(i) Designates a patient of record upon whom services are to be performed.

(ii) Is physically present in the office at the time the procedures are being performed.”

Further, “‘monitoring’ means observing levels and reporting to the dentist or dental hygienist.”

An Out-of-Date Way of Thinking About Fillers and Botox in Dentistry

The state of Michigan is behind the times with respect to allowing general dentists to perform Botox and filler injections for dental and/or cosmetic reasons — and times are rapidly changing. At least one national author maintains a general dentist may perform cosmetic Botox.

The safest understanding of the current philosophy of the Board is that:

    1. A general dentist without training cannot perform Botox or filler injections.
    2. With training, a general dentist may perform Botox and filler injections as long as he/she complies with MCL 333.16601(d) which defines dentistry as “the diagnosis, treatment, prescription, or operation for a disease, pain, deformity, deficiency, injury, or physical condition of human tooth, teeth, alveolar process, gums or jaws, or their dependent tissue, or an offer, undertaking, attempt to do, or holding oneself out as able to do any of these acts.” (Emphasis added.) The decision each dentist must make based on his/her judgment is what dependent tissue is involved in treating a problem of the “disease, pain, deformity, deficiency, injury, or physical condition of the tooth, teeth, alveolar process gums or jaws …”
    3. A dental hygienist may be delegated the task of doing the injections if he/she has the specialized training and is under the direct supervision of the dentist, which is defined in MCL 3334.1611(b) as outlined above.

Chapman Law Group: We are Your Dental Attorneys

For 35 years, Chapman Law Group’s healthcare attorneys have been representing dentists, dental hygienists, dental labs and dental radiographers. We handle the most complex of dental matters, including professional liability/dental malpractice, licensure, regulatory compliance, health care fraud and abuse, DEA issues, and criminal actions.

Contact Chapman Law Group today to schedule a consultation with one of our experienced dentist and dental hygienist attorneys.

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