RUNNING HEAD: Knowledge and practice of faculty members on non-surgical facial aesthetics

Knowledge and practice of faculty members on non-surgical facial aesthetics5

Type of Article: Original Article

Knowledge and practice of faculty members of dental colleges in Saudi Arabia on non-surgical facial aesthetics (Botox & Dermal Fillers)

Running Title: Knowledge and practice of faculty members on non-surgical facial aesthetics

Authors:

Souad Alfouzan1, Maha Mekkawy2

1- Dental Intern, College of Dentistry, Qassim University, Saudi Arabia

2- Assistant Professor, Department of Removable Prosthodontics, College of Dentistry, Qassim University, Saudi Arabia

Corresponding Author:

Name: Dr. Souad Alfouzan

Affiliation: Dental intern, College of Dentistry, Qassim university, Saudi Arabia

Email: souad.alfouzan@qudent.org

Phone number: +966558723059

Abstract

Background: Botulinum toxin (BTX) and dermal fillers (DF) are some of the most popular aesthetic interventions used nowadays. This study aimed to evaluate the knowledge and opinions of the use of botulinum toxin (BTX) and dermal fillers (DF) in aesthetic and therapeutic dental treatment by dental faculty members of different dental colleges in Saudi Arabia.

Methodology: In the current study, 245 questionnaires were distributed to faculty members of Saudi dental colleges to assess their knowledge of non-surgical facial aesthetic (NSFA) procedures. The questionnaire consisted of questions about the indications and side effects of botulinum toxin and dermal filler types.

Results: Among the participants, 35.5% knew about the therapeutic uses of BTX, 88.6% thought that wrinkle reduction was the most common indication of BTX. Among the participants, 80% chose lip augmentation as the most common indication of dermal fillers, whereas 40.8% of participants thought that allergic reaction was more commonly seen with BTX; however, 36% thought that asymmetry was more associated with dermal fillers. A statistically significant difference was observed across genders about the indications and side effects of BTX (P ≤0.05).

Conclusion: It was found that faculty members in Saudi Arabia had limited knowledge about NSFA source, dosage, side effects, and applications. Female faculty members of Saudi dental colleges have a significantly better knowledge about NSFA types and indications.

Keywords: Botulinum toxin, dental aesthetic, dermal fillers, Saudi Arabia

Introduction

The demand for various aesthetic procedures is increasing. Nowadays, non-surgical facial aesthetic (NSFA) procedures are among the most popular aesthetic interventions [1]. In 2017 there were more than eight million non-surgical facial procedures reported worldwide by the International Society of Aesthetic Plastic Surgery [2].

Botulinum toxin (BTX) is a neurotoxin produced by the gram-negative bacterium Clostridium Botulinum. Seven strains of botulinum toxins (A, B, C, D, E, F, and G) have been identified in the literature. Neurotoxin strains A and B are commercially available for medical treatments [3]. BTX has a variety of therapeutic and cosmetic uses. It reduces facial wrinkles, hyperhidrosis, chronic migraine, tremors, and tics [4,5]. It can conservatively treat dental-related problems, such as clenching, bruxism, temporomandibular joint disorders, mandibular spasm, sialorrhea, and trigeminal neuralgia [5,6].

BTX can be used to retrain hyperactive muscles in patients with new dentures having decreased vertical dimension and long-term teeth loss [6,7]. BTX is a non-invasive approach in treating dental aesthetic cases like excessive gingival display [8,9]. With age, there is a loss of tissue fullness around lips and nasolabial fold that makes a person looks older. Dermal filler (DF) has been used to fill and restore tissue volume, especially in the lower face region [10].

In dentistry, DF is used to restore lip fullness in edentulous and partially edentulous patients [11]. It also shows successful results for gummy smile treatment, lip incompetence, marionette lines, lower face wrinkles, and smile asymmetry [12]. Black triangles, which are the most challenging aesthetic problem, can be treated with hyaluronic acid fillers as a non-invasive approach to treatment [13,14].

Although the application of BTX and DF in dentistry has increased globally in recent years, their dental application in Saudi Arabia is minimally investigated [15]. Accordingly, this study aimed to evaluate the knowledge and practices of faculty members in different dental colleges in Saudi Arabia about the use of BTX and DF in aesthetic and therapeutic dental treatment.

Subjects and Methods

A questionnaire was developed to assess the knowledge of dental faculty members about NSFA. The questions were formulated based on previous literature [15]. Informed consent and the purpose of the study were written on the questionnaire's front page.

The questionnaire consisted of three parts. The first part gathered demographic data, such as gender, workplace, academic position, and specialty. The second part consisted of six questions regarding the BTX source, doses, indication, and side effects. The third part had four questions about DF types, indications, and side effects. A pilot study was performed with ten faculty members of Qassim University to assess the clarity and acceptability of questions. Minor changes were made according to their comments and suggestions before distributing the questionnaire. Three hundred questionnaires were distributed by students from different universities.

Data were analyzed using the Statistical Package for the Social Sciences version 21. Descriptive analysis was done for all the data, and crosstab analysis was used to compare the gender, specialty, and academic position of faculty members in their knowledge about NSFA. The Chi-Square test was used to measure the significance level, which was set to (P ≤0.05).

Results

Out of 300 questionnaires, 245 questionnaires were completed and returned. Table1 shows the departments of the participants who answered the questionnaire.

Table 1: Demographic data of participants

Department

Gender

Total

Male

Female

Dental material

0

1

1

Oral & maxillofacial surgery

19

23

42

Restorative dentistry

24

27

51

Prosthodontics

19

22

41

Periodontology

15

25

40

Orthodontics

4

6

10

Endodontics

9

13

22

Pedodontics

8

11

19

Oral medicine

4

4

8

Community dentistry

4

7

11

Total

106

139

245

Participants were asked about the source of BTX; 53.1% agreed that the bacterium Clostridium is the source, and 42.9% stated that they did not know. When participants were asked about BTX dosage, only 35.5% knew that therapeutic uses required higher doses than cosmetic uses. Similarly, 55% of participants did not know that males require higher doses than females, whereas 60% did not know that injection into the lower face requires lower doses than the upper face, as shown in Table 2.

Table 2: BTX source and dosage

Questions

Gender

Agree

Disagree

Do not know

P-value

The Source of botulinum toxin is the bacterium Clostridium

male

54

5

47

0.803

female

76

5

58

Therapeutic uses require higher doses than cosmetic uses

male

39

17

50

0.551

female

48

30

61

Male requires higher doses than female

male

12

31

63

0.108

female

30

36

73

Injection at lower face muscles require a higher dose

male

18

15

73

0.046*

female

34

31

74

Participants were asked about BTX indications; 88.6% agreed that wrinkle reduction is the most common indication, followed by 74.7% for relaxing hyperactive muscles, 70.6% for a gummy smile, 51.8% for temporomandibular joint problems, 44.5% for jaw clenching, and 35.9% for headache, as shown in Table 3. There was a statistically significant difference across genders about knowledge of the indications of BTX (P ≤0.05). When participants were asked about the side effects of BTX, 40.8% answered that allergic reactions occasionally happened, and 34.3% mentioned droopy eyelids, as shown in Table 4.

Table 3: BTX indications

Indications

Gender

Agree

Disagree

Do not know

P-value

TMJ problems

male

47

17

42

0.068

female

80

12

47

Gummy smile

male

62

13

31

0.001*

female

111

11

17

Wrinkle reduction

male

89

2

15

0.04*

female

128

4

7

Relaxing hyperactive muscles

male

68

6

32

0.001*

female

115

9

15

Jaw clenching

male

39

20

47

0.103

female

70

22

47

Headache

male

26

35

45

0.003*

female

62

28

49

Table 4: BTX side effects

Side effects

Gender

Common

Occasionally

Rare

Do not know

P.value

Allergy

male

17

42

17

30

0.07

female

19

58

38

24

Droopy eyelids

male

10

41

11

44

0.01*

female

37

43

24

35

Soreness & bleeding at injection site

male

17

29

23

37

0.03*

female

39

44

27

29

Lack of intended effect of Botox

male

12

32

18

44

0.165

female

25

46

28

40

Headache

male

8

17

25

56

0.054*

female

10

34

45

50

Participants answered two questions about DF types; 37.6% answered that hyaluronic acid is a biodegradable material, and 44.5% answered that silicone is a non-biodegradable material, as shown in Table 5.

Table 5: DF types

Types

Gender

Biodegradable

Non-biodegradable

Do not know

P-value

Hyaluronic acid

male

26

27

53

0.001*

female

66

27

46

Silicone

male

19

38

49

0.02*

female

27

71

41

Regarding DF indications, the majority of the participants (80%) chose lip augmentation, 78% filing nasolabial line, 77% facial contouring, 71% cheek, and chin enhancement, 69% asymmetrical lips, and lastly, 48% high lip line, as shown in Table 6. When participants were asked about the side effects of DF, 36% chose asymmetry, 34% under or over correction of wrinkles, 31% infection, and 28% chose bruising and bleeding as occasional side effects, as shown in Table7. There was a statistically significant difference in knowledge across genders about types, indications, and side effects of DF (P ≤0.05).

Table 6: DF indications

Indications

Gender

Agree

Disagree

Do not know

P-value

Filing nasolabial line

male

75

2

29

0.027*

female

116

4

19

Lip augmentation

male

78

3

25

0.027*

female

119

5

15

Facial contouring

male

73

5

20

0.014*

female

117

2

48

Cheek & chin enhancement

male

66

6

34

0.012*

female

119

2

28

Asymmetrical lips

male

65

9

32

0.029*

female

105

4

30

High lip line

male

40

20

46

0.009*

female

79

22

38

Table 7: DF side effects

Side effects

Gender

Common

Occasionally

Rare

Do not know

P-value

Infection

male

10

31

30

35

0.014*

female

29

45

40

25

Asymmetry

male

23

36

16

31

0.023*

female

49

53

12

25

Bruising & bleeding

male

19

27

25

35

0.002*

female

49

43

23

24

Under or over correction

male

22

36

10

38

0.126*

female

44

46

13

33

Discussion

BTX is a neurotoxin produced by anaerobic bacteria Clostridium Botulinum and was originally identified in 1895 by Justinus Kerner but was not successfully isolated until 1920 [16]. In the present study, about 53% of the participants showed better knowledge about the source of BTX than the 34% reported by Al-Hamdan et al. when they assessed knowledge about BTX among dentists in Riyadh [15]. This can be explained by the difference in educational level between our samples.

The therapeutic benefits of BTX were first introduced for the treatment of strabismus in 1980, then blepharospasm, cervical dystonia, and primary axillary hyperhidrosis were introduced [17-19]. Therapeutic indications usually require higher doses than cosmetic indications [20]. In this study, about 45% of participants did not know about dosage differences. This can be explained by a lack of experience and practice since only 3% of the sample have practiced BTX, as shown in Figure 1.

Understanding the anatomy of the face and physiology of facial expressions is the key element in the success of any facial procedure. Male patients require higher doses of BTX than females, as reported in the literature. This difference can be explained by the fact that they have a higher mass of muscles than females [21]. Almost 55% of our participants did not realize the differences reported by the previous study [15].

The response of the lower facial muscles to BTX is greater than that of the upper facial muscle for an equivalent BTX dose. Therefore, the lower face doses need to be lower by at least one half to one third per muscle compared to the upper face [22]. As mentioned earlier, since participants of this study have not practiced BTX injection before, 60% did not know the dosage difference, and 21% answered that the lower face requires a higher dose as they relate with masseter muscle bulkiness.

BTX has many therapeutic and cosmetic indications that have been approved by the Food and Drug Administration (FDA). In 1989 the FDA approved it for eye muscle involuntary contractions, in 2000 for cervical dystonia, and in 2002 FDA has extended the approval to include the first cosmetic indication and treatment of glabellar wrinkles [23]. From 2002 until now, it has become the first and most popular non-surgical facial procedure in the United States. This explains why wrinkle reduction was the most chosen answer among participants (88.6%), followed by 74.7% for relaxing hyperactive muscles, reflecting the participants' knowledge about the BTX mechanism.

The excessive gingival display is a challenging case in aesthetic dentistry. Apart from various surgical techniques that have been used for the treatment of gummy smiles, the application of botulinum toxin has shown promising results for gummy smile correction [24]. In comparison to the previous study, 70.6% of our participants showed good knowledge of gummy smile treatment with BTX compared to 51% in the previous study [15].

Although BTX is considered a safe, non-surgical, and non-invasive treatment modality, FDA has reported some side effects after injection of BTX. The most common was the lack of effect (63%), followed by the injection site reaction (19%) and ptosis (11%) [25]. In our study, 40.8% answered allergic reaction followed by 34.3% droopy eyelids, which was consistent with the previous study that showed that participants thought any foreign material injected into the body might elicit foreign body reaction [15].

Currently, hyaluronic acids (HA) are the dominant biodegradable facial filler agent that the FDA has approved for use in 2003. HA is also a major component of connective tissues, especially in the human dermis. It hydrates, lubricates, and stabilizes connective tissues. It is from a non-bovine source, which decreases the likelihood of allergic reactions [26]. On the other hand, a silicone type filler is a non-biodegradable filler, which has not been approved by the FDA for injection to fill wrinkles or augment tissues anywhere in the body. However, 44.6% of participants know the type of silicone as a non-biodegradable type, and 37.6% have previous knowledge that HA is biodegradable with a significant difference between females and males (p<0.001). This may be due to the fact that females are more interested and have experienced dermal fillers. As people become more aware of cosmetic treatments, their interest in wanting to achieve a younger look is increasing day by day.

Our participants showed excellent knowledge regarding DF indications, with a significant difference between females and males (p<0.02). Most reported indications were lip augmentation 80%, filling nasolabial line 78%, facial contouring 77%, cheek and chin enhancement 71%, and asymmetrical lips 69%, and lastly high lip line 48%, which was higher than the previous study reported around 50% for lip augmentation [15]. This reflects the background knowledge of participants that dermal fillers are meant to increase the volume, so lip augmentation comes first into their minds.

In the previous study, one of the most reported side effects was infection 41%, which is comparable to our findings since most participants think any needle injection may result in infection at the site of injection [15].

Conclusion

Within the limitation of the current study, limited knowledge was found among dental faculty members in Saudi Arabia about NSFA source, dosage, side effects, and applications. Dental practitioners in Saudi Arabia are encouraged to seek further knowledge to introduce BTX and DF treatment modalities in dentistry and offer patients the most desirable therapeutic and aesthetic results.

Conflict of Interests:

The authors declare that there is no conflict of interest regarding the publication of this article.

Funding:

None

Consent for publication:

Informed consent was obtained from all the participants.

Ethical Approval:

Ethical approval was granted by the Research and Ethics Committee of the College of Dentistry, Qassim University, ref #(F-2018-3002).

List of Abbreviations

Botulinum toxin:BTX

Dermal filler:DF

Food and Drug Administration:FDA

Hyaluronic acid:HA

Non-surgical facial aesthetic:NSFA

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