The area of botulinum toxin and dermal fillers is evolving in the general Australian dental context as a result of community and professional expectations.
When considering the provision of Botox and dermal fillers, the Dental Board of Australia (DBA) expects dentists to understand and practice in accordance with:
- the definition of dentistry:
“Dentistry involves the assessment, prevention, diagnosis, advice, and treatment of any injuries, diseases, deficiencies, deformities or lesions on or of the human teeth, mouth or jaws or associated structures.”
- the DBA’s Standards, Codes and Guidelines by:
- performing only those procedures that fall within their scope of practice i.e. for which they have been educated and trained, and are competent to provide
- maintaining a high level of professional competence and conduct, including expectations around informed and financial
- the relevant state and territory drugs and poisons legislation and regulations by using scheduled medicines only ‘for dental therapeutic use’.
- the requirements of the Therapeutic Goods Administration (TGA) in relation to:
- the advertising of therapeutic goods
- ‘off-label’ use of botulinum toxin and dermal fillers
- approved uses of botulinum toxin and dermal fillers for use in Dentists in NSW should only purchase these products from an approved source.
In addition, the DBA expects dentists to refer a patient to a suitably trained and qualified:
- dental practitioner – when the treatment required by the patient is outside the personal scope of practice of the individual dentist, but still within the definition of dentistry, or
- medical practitioner – when the proposed treatment is outside the definition of dentistry.
Is the use of botulinum toxin and dermal fillers by dentists within their scope of practice?
Practitioners are required to practice within both their:
- Personal Scope: this relates to the procedures they feel comfortable to provide because they are competent to do so through appropriate education and training; and
- Scope of Practice of the Dental Profession: all treatment that falls within the definition of dentistry.
Will I be subject to regulatory action for treating areas outside the bottom third of the face?
The Code of Conduct describes the expectations of what constitutes good practice. Dental practitioners have a duty to make the care of patients their first concern and to practise safely and effectively at all times.
The DBA’s position is that the treatment must fall within the practice of dentistry, and practitioners should practice within their personal scope of practice.
Treatment outside the lower third of the face could be considered the practice of dentistry if it was justifiably related to treatment “of the human teeth, mouth, jaws or associated structures”.
Botulinum toxin and dermal fillers should only be used if the treatment can be justified and is clinically indicated.
All procedures carry risks and complications, and the wellbeing of our patients is paramount. Complications and adverse events from the injection of botulinum toxin or dermal fillers can be serious and, if delivered inappropriately, can lead to serious legal and professional consequences. Informed consent (including informed financial consent) must be obtained and the risks associated with the treatment explained to the patient and documented.
Why isn’t there clarity as to the “Practice of Dentistry” and “Associated Structures”?
The definition of dentistry is designed to be flexible with advances in knowledge, materials, techniques and community views that are constantly evolving. Although the DBA does not define “associated structures”, it is expected that practitioners exercise their professional judgement as to which anatomical structures are included in their care.
Are dentists able to use botulinum toxin and/or dermal fillers ‘off-label’?
The use of botulinum toxin for the treatment of TMJ disorders is considered off label and experimental, as is the use of botulinum toxin and dermal fillers for cosmetic purposes. Practitioners therefore need to rely on their clinical judgement of risks versus benefits based on the patient’s clinical need and decide in consultation with their patient. The patient must be made aware that the proposed use is experimental only and all risks must be explained. Informed consent from the patient must be obtained in writing. Documentation must be precise and include informed financial consent.
Can a dentist delegate the administration of botulinum toxin and dermal fillers to someone else?
Dentists are prohibited from on-supplying restricted medicines for therapeutic use to others. Prosthetists, hygienists, dental therapists and oral health therapists are not allowed to perform these procedures irrespective of any training they might have received. The dentist must take responsibility for the receipt, security and administration of scheduled medicines.
Advertising
Any person, including businesses, advertising the use of botulinum toxin and/or dermal fillers must comply with both the TGA’s requirements when advertising a therapeutic good (that limit the reference to the substance) and the DBA’s Guidelines for advertising.
https://www.tga.gov.au/news/media-releases/referring-cosmetic-injectables-advertising
Insurance
There has been confusion throughout the dental profession in NSW and the ACT in respect to Professional Indemnity insurance cover for the use of botulinum toxin and dermal fillers.
Dental Indemnity policies are designed to cover you for the “Practice of Dentistry”. If you are found to be working outside a dentist’s scope of practice, you risk NOT being indemnified for the procedures you perform because your policy will not be triggered. This is valid for EVERY insurer because it is the basis of dental indemnity insurance policies.
Guild Insurance’s professional indemnity policy has always covered dentists for claims arising out of the practice of dentistry and restricted dental acts, including the use of Botox (botulinum toxin) and dermal fillers.
Which is the correct item code for injection of botulinum toxin or other agents
The ADA recommends using Item Number 927. There are no specific item numbers within Medicare or other schedules for botulinum toxin and dermal fillers for use by a dental practitioner. Arrangements for these treatments provided by a dental practitioner are currently not recognised by Medicare.
Will private health insurers pay a benefit for treatment that includes botulinum toxin and dermal fillers?
Private Health Insurers (PHI) have different rules (and different policies) when it comes to the treatments for which they will pay a benefit. Patients should be encouraged to contact their health fund for this information.
SUMMARY OF ADVICE TO MEMBERS:
- Only perform procedures for which you are trained and competent.
- When using Continuing Professional Development (CPD) to extend your personal scope, select courses carefully (but remember that you cannot use CPD to extend your scope beyond what would be considered dentistry).
- Ensure you obtain fully informed consent from your patients, including being clear about your qualifications, and offer the opportunity to refer the patient to a specialist. Consent is critical when using botulinum toxin and dermal fillers.
Further information is available at Dental Board of Australia – Fact sheet: The use of botulinum toxin and dermal fillers by dentists
Related Information
Practitioners may wish to consider the information in relation to Consent and Scope of Practice. Further information is available at the ADA NSW website. To view and download the available ADA NSW Information Sheets, click on the following link
https://www.adansw.com.au/Members/AdvisoryServices/InformationSheets
- Consent Information Sheet
- Scope of Practice Information Sheet
Disclaimer: This is one of a series of Advisory Services information sheets created by ADA NSW. They are intended as general guides that highlight key pieces of information frequently requested. They do not set out to provide comprehensive information about a topic and they are not legal advice. Please be mindful that information provided in these resources can change after the publication date.
