Knowledge and practice of faculty members of dental colleges in Saudi Arabia on non-surgical facial aesthetics (botox & dermal fillers)
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Souad Alfouzan et al, 2021;5(2):595–600. International Journal of Medicine in Developing Countries
https://doi.org/10.24911/IJMDC.51-1609079111
ORIGINAL ARTICLE
Knowledge and practice of faculty
members of dental colleges in Saudi
Arabia on non-surgical facial aesthetics
(botox & dermal fillers)
Souad Alfouzan1*, Maha Mekkawy2
ABSTRACT
Background: Botulinum toxin (BTX) and dermal fillers (DF) are some of the most popular aesthetic interven-
tions used nowadays. This study aimed to evaluate the knowledge and opinions of the use of BTX and DF in aes-
thetic 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 con-
sisted 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, dos-
age, 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 BTX can be used to retrain hyperactive muscles in
increasing. Nowadays, non-surgical facial aesthetic patients with new dentures having decreased vertical
(NSFA) procedures are among the most popular dimension and long-term teeth loss [6,7]. BTX is a non-
aesthetic interventions [1]. In 2017, there were more than invasive approach in treating dental aesthetic cases like
eight million non-surgical facial procedures reported excessive gingival display [8,9]. With age, there is a loss
worldwide by the International Society of Aesthetic of tissue fullness around lips and nasolabial fold that
Plastic Surgery [2]. makes a person looks older. Dermal filler (DF) has been
used to fill and restore tissue volume, especially in the
Botulinum toxin (BTX) is a neurotoxin produced by the
lower face region [10].
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
Correspondence to: Souad Alfouzan
B are commercially available for medical treatments [3].
*Dental intern, College of Dentistry, Qassim university,
BTX has a variety of therapeutic and cosmetic uses. It Saudi Arabia.
reduces facial wrinkles, hyperhidrosis, chronic migraine, Email: souad.alfouzan@qudent.org
tremors, and tics [4,5]. It can conservatively treat Full list of author information is available at the end of
dental-related problems, such as clenching, bruxism, the article.
temporomandibular joint disorders, mandibular spasm, Received: 27 December 2020| Accepted: 09 January 2021
sialorrhea, and trigeminal neuralgia [5,6].
© IJMDC. https://www.ijmdc.com 595Knowledge and practice of faculty members on non-surgical facial aesthetics
In dentistry, DF is used to restore lip fullness in indication, followed by 74.7% for relaxing hyperactive
edentulous and partially edentulous patients [11]. It also muscles, 70.6% for a gummy smile, 51.8% for
shows successful results for gummy smile treatment, lip temporomandibular joint problems, 44.5% for jaw
incompetence, marionette lines, lower face wrinkles, clenching, and 35.9% for headache, as shown in Table 3.
and smile asymmetry [12]. Black triangles, which are There was a statistically significant difference across
the most challenging aesthetic problem, can be treated genders about knowledge of the indications of BTX (p
with hyaluronic acid fillers as a non-invasive approach to ≤ 0.05). When participants were asked about the side
treatment [13,14]. effects of BTX, 40.8% answered that allergic reactions
Although the application of BTX and DF in dentistry occasionally happened, and 34.3% mentioned droopy
has increased globally in recent years, their dental eyelids, as shown in Table 4.
application in Saudi Arabia is minimally investigated Participants answered two questions about DF types;
[15]. Accordingly, this study aimed to evaluate the 37.6% answered that hyaluronic acid is a biodegradable
knowledge and practices of faculty members in different material, and 44.5% answered that silicone is a non-
dental colleges in Saudi Arabia about the use of BTX and biodegradable material, as shown in Table 5.
DF in aesthetic and therapeutic dental treatment.
Regarding DF indications, the majority of the participants
Subjects and Methods (80%) chose lip augmentation, 78% filing nasolabial
line, 77% facial contouring, 71% cheek, and chin
A questionnaire was developed to assess the knowledge of enhancement, 69% asymmetrical lips, and lastly, 48%
dental faculty members about NSFA. The questions were high lip line, as shown in Table 6. When participants
formulated based on previous literature [15]. Informed were asked about the side effects of DF, 36% chose
consent and the purpose of the study were written on the asymmetry, 34% under or over correction of wrinkles,
questionnaire's front page. 31% infection, and 28% chose bruising and bleeding as
occasional side effects, as shown in Table 7. There was
The questionnaire consisted of three parts. The first part a statistically significant difference in knowledge across
gathered demographic data, such as gender, workplace, genders about types, indications, and side effects of DF
academic position, and specialty. The second part (p ≤ 0.05).
consisted of six questions regarding the BTX source,
doses, indication, and side effects. The third part had four Discussion
questions about DF types, indications, and side effects. A
pilot study was performed with 10 faculty members of BTX is a neurotoxin produced by anaerobic bacteria
Qassim University to assess the clarity and acceptability Clostridium Botulinum and was originally identified
of questions. Minor changes were made according to in 1895 by Justinus Kerner but was not successfully
their comments and suggestions before distributing isolated until 1920 [16]. In the present study, about 53%
the questionnaire. Three hundred questionnaires were of the participants showed better knowledge about the
distributed by students from different universities. source of BTX than the 34% reported by Al-Hamdan
et al. [15] when they assessed knowledge about BTX
Data were analyzed using the Statistical Package for the
among dentists in Riyadh. This can be explained by the
Social Sciences version 21. Descriptive analysis was
difference in educational level between our samples.
done for all the data, and crosstab analysis was used to
compare the gender, specialty, and academic position of The therapeutic benefits of BTX were first introduced for
faculty members in their knowledge about NSFA. The the treatment of strabismus in 1980, then blepharospasm,
Chi-Square test was used to measure the significance
level, which was set to (p ≤0.05).
Table 1. Demographic data of participants.
Results
Gender
Department Total
Out of 300 questionnaires, 245 questionnaires were Male Female
completed and returned. Table 1 shows the departments Dental material 0 1 1
of the participants who answered the questionnaire.
Oral & maxillofacial surgery 19 23 42
Participants were asked about the source of BTX; 53.1% Restorative dentistry 24 27 51
agreed that the bacterium Clostridium is the source, and
Prosthodontics 19 22 41
42.9% stated that they did not know. When participants
were asked about BTX dosage, only 35.5% knew that Periodontology 15 25 40
therapeutic uses required higher doses than cosmetic Orthodontics 4 6 10
uses. Similarly, 55% of participants did not know that Endodontics 9 13 22
males require higher doses than females, whereas 60% Pedodontics 8 11 19
did not know that injection into the lower face requires
Oral medicine 4 4 8
lower doses than the upper face, as shown in Table 2.
Community dentistry 4 7 11
Participants were asked about BTX indications; 88.6%
Total 106 139 245
agreed that wrinkle reduction is the most common
596Knowledge and practice of faculty members on non-surgical facial aesthetics
Table 2. BTX source and dosage.
Questions Gender Agree Disagree Do not know p-value
The Source of botulinum toxin is the bacterium Male 54 5 47
0.803
Clostridium Female 76 5 58
Therapeutic uses require higher doses than Male 39 17 50
0.551
cosmetic uses Female 48 30 61
Male 12 31 63
Male requires higher doses than female 0.108
Female 30 36 73
Injection at lower face muscles require a higher Male 18 15 73
0.046*
dose Female 34 31 74
Table 3. BTX indications.
Indications Gender Agree Disagree Do not know p-value
Male 47 17 42
TMJ problems 0.068
Female 80 12 47
Male 62 13 31
Gummy smile 0.001*
Female 111 11 17
Male 89 2 15
Wrinkle reduction 0.04*
Female 128 4 7
Relaxing hyperactive Male 68 6 32
0.001*
muscles Female 115 9 15
Male 39 20 47
Jaw clenching 0.103
Female 70 22 47
Male 26 35 45
Headache 0.003*
Female 62 28 49
Table 4. BTX side effects.
Side effects Gender Common Occasionally Rare Do not know p value
Male 17 42 17 30
Allergy 0.07
Female 19 58 38 24
Male 10 41 11 44
Droopy eyelids 0.01*
Female 37 43 24 35
Soreness & bleeding Male 17 29 23 37
0.03*
at injection site Female 39 44 27 29
Lack of intended Male 12 32 18 44
0.165
effect of Botox Female 25 46 28 40
Male 8 17 25 56
Headache 0.054*
Female 10 34 45 50
cervical dystonia, and primary axillary hyperhidrosis any facial procedure. Male patients require higher doses
were introduced [17-19]. Therapeutic indications usually of BTX than females, as reported in the literature. This
require higher doses than cosmetic indications [20]. In difference can be explained by the fact that they have a
this study, about 45% of participants did not know about higher mass of muscles than females [21]. Almost 55%
dosage differences. This can be explained by a lack of of our participants did not realize the differences reported
experience and practice since only 3% of the sample by the previous study [15].
have practiced BTX, as shown in Figure 1. The response of the lower facial muscles to BTX is greater
Understanding the anatomy of the face and physiology than that of the upper facial muscle for an equivalent BTX
of facial expressions is the key element in the success of dose. Therefore, the lower face doses need to be lower by
597Knowledge and practice of faculty members on non-surgical facial aesthetics
Table 5. DF types.
Types Gender Biodegradable Non-biodegradable Do not know p-value
Male 26 27 53
Hyaluronic acid 0.001*
Female 66 27 46
Male 19 38 49
Silicone 0.02*
Female 27 71 41
Table 6. DF indications.
Indications Gender Agree Disagree Do not know p-value
Male 75 2 29
Filing nasolabial line 0.027*
Female 116 4 19
Male 78 3 25
Lip augmentation 0.027*
Female 119 5 15
Male 73 5 20
Facial contouring 0.014*
Female 117 2 48
Male 66 6 34
Cheek & chin enhancement 0.012*
Female 119 2 28
Male 65 9 32
Asymmetrical lips 0.029*
Female 105 4 30
Male 40 20 46
High lip line 0.009*
Female 79 22 38
Table 7. DF side effects.
Side effects Gender Common Occasionally Rare Do not know p-value
Male 10 31 30 35
Infection 0.014*
Female 29 45 40 25
Male 23 36 16 31
Asymmetry 0.023*
Female 49 53 12 25
Bruising & Male 19 27 25 35
0.002*
bleeding Female 49 43 23 24
Under or over Male 22 36 10 38
0.126*
correction Female 44 46 13 33
Figure 1. NSFA practice among participants.
at least one half to one third per muscle compared to the 60% did not know the dosage difference, and 21%
upper face [22]. As mentioned earlier, since participants answered that the lower face requires a higher dose as
of this study have not practiced BTX injection before, they relate with masseter muscle bulkiness.
598Knowledge and practice of faculty members on non-surgical facial aesthetics
BTX has many therapeutic and cosmetic indications that background knowledge of participants that dermal fillers
have been approved by the Food and Drug Administration are meant to increase the volume, so lip augmentation
(FDA). In 1989 the FDA approved it for eye muscle comes first into their minds.
involuntary contractions, in 2000 for cervical dystonia, In the previous study, one of the most reported side effects
and in 2002 FDA has extended the approval to include was infection 41%, which is comparable to our findings
the first cosmetic indication and treatment of glabellar since most participants think any needle injection may
wrinkles [23]. From 2002 until now, it has become the result in infection at the site of injection [15].
first and most popular non-surgical facial procedure in
the United States. This explains why wrinkle reduction Conclusion
was the most chosen answer among participants (88.6%),
followed by 74.7% for relaxing hyperactive muscles, Within the limitation of the current study, limited
reflecting the participants' knowledge about the BTX knowledge was found among dental faculty members in
mechanism. Saudi Arabia about NSFA source, dosage, side effects,
The excessive gingival display is a challenging case in and applications. Dental practitioners in Saudi Arabia
aesthetic dentistry. Apart from various surgical techniques are encouraged to seek further knowledge to introduce
that have been used for the treatment of gummy smiles, BTX and DF treatment modalities in dentistry and offer
the application of botulinum toxin has shown promising patients the most desirable therapeutic and aesthetic
results for gummy smile correction [24]. In comparison results.
to the previous study, 70.6% of our participants showed List of Abbreviations
good knowledge of gummy smile treatment with BTX BTX Botulinum toxin
compared to 51% in the previous study [15]. DF Dermal filler
Although BTX is considered a safe, non-surgical, and FDA Food and Drug Administration
non-invasive treatment modality, FDA has reported some HA Hyaluronic acid
side effects after injection of BTX. The most common NSFA Non-surgical facial aesthetic
was the lack of effect (63%), followed by the injection
site reaction (19%) and ptosis (11%) [25]. In our study, Conflict of interests
40.8% answered allergic reaction followed by 34.3% The authors declare that there is no conflict of interest
droopy eyelids, which was consistent with the previous regarding the publication of this article.
study that showed that participants thought any foreign Funding
material injected into the body might elicit foreign body None.
reaction [15].
Consent for publication
Currently, hyaluronic acids (HA) are the dominant
Informed consent was obtained from all the participants.
biodegradable facial filler agent that the FDA has
approved for use in 2003. HA is also a major component Ethical approval
of connective tissues, especially in the human dermis. It Ethical approval was granted by the Research and Ethics
hydrates, lubricates, and stabilizes connective tissues. Committee of the College of Dentistry, Qassim University, ref
It is from a non-bovine source, which decreases the #(F-2018-3002).
likelihood of allergic reactions [26]. On the other hand,
a silicone type filler is a non-biodegradable filler, which Author details
has not been approved by the FDA for injection to fill Souad Alfouzan1, Maha Mekkawy2
wrinkles or augment tissues anywhere in the body. 1. Dental Intern, College of Dentistry, Qassim University,
However, 44.6% of participants know the type of silicone Saudi Arabia
as a non-biodegradable type, and 37.6% have previous 2. Assistant Professor, Department of Removable
knowledge that HA is biodegradable with a significant Prosthodontics, College of Dentistry, Qassim University,
difference between females and males (p < 0.001). This Saudi Arabia
may be due to the fact that females are more interested
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