Botox in Periodontics: A Paradigm Shift in Treatment Modalities - A Questionnaire Based Study

Introduction

For several decades, facial aesthetic procedures have constituted a common component of dental and periodontal practice. With increasing patient expectations, the demand for facial aesthetics has prompted the development of new approaches to optimize outcomes. It is widely accepted that first impressions are lasting, and dental aesthetics is a vital element of this perception.¹ Since many expressions are communicated through a smile, the demand for an ideal smile has increased. Dentofacial harmony depends on three key factors - the lips, teeth, and gingival architecture, that collectively determines the aesthetics of a smile, which is central to all expressions. Patients with a gummy smile (GS) may experience both aesthetic and psychological concerns, as it can lead to a loss of self-confidence in smiling.²

Periodontology is a branch of dentistry that not only deals with the tooth supporting structures but also contributes to facial aesthetics and the harmony among the lips, teeth, and gingiva. From a periodontal perspective, several gingival factors play a significant role in determining facial aesthetics.^3,4 In recent years, there has been a marked increase in minimally invasive cosmetic procedures, one of which is the use of Botox type A (onabotulinumtoxinA).^5-7 Botulinum toxin (Botox) is a potent, natural neurotoxin produced by Clostridium botulinum.⁸ Currently, seven serotypes of botulinum neurotoxin have been found (serotypes A to G).⁹ Despite its lethal properties, the protein has demonstrated significant medical benefits. Presently, three formulations of type A botulinum toxin (Botox, Dysport, Xeomin) and one formulation of type B (MyoBloc) are available for use in cosmetic and medical procedures.¹⁰

Botulinum toxin is widely utilized in both medical and dental fields for diverse applications. It has been used in facial esthetics as an anti-wrinkle agent, and has also been employed in the treatment of specific lacrimal gland diseases, habitual headaches, children with cerebral paralysis, myofunctional pain and occlusal function, bruxism, dental implants, gummy smile.¹

Materials and Methods

This cross-sectional survey included 264 subjects, with ethical approval obtained from the Institutional Review Board of Sri Rajiv Gandhi College of Dental Sciences and Hospital, Bangalore. Data were collected using an online Google Form, and the questionnaire comprised 15 items: five assessing knowledge, five evaluating attitude, and five addressing practice.

The questionnaire was designed to assess knowledge, attitude, and practice regarding the use of botulinum toxin (BTX) as a potential treatment modality for gummy smile and its application in periodontics.

The Google Form was distributed to periodontists and postgraduate students in periodontics across Bangalore, and their responses were collected.

Statistical analysis

Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) for Windows, Version 22.0 (Released 2013; IBM Corp., Armonk, NY). Descriptive statistics were calculated using mean and standard deviation for quantitative variables, and frequency and proportions for categorical variables. The Chi-square test was applied to compare responses related to knowledge and awareness of Botox use in the treatment of periodontitis across key demographic variables. A P-value of <0.05 was considered statistically significant.

Results

A total of 264 participants took part in this questionnaire survey,of which 136 (51.5%) were postgraduate students specializing in periodontics, and 128 (48.5%) were periodontists from Bangalore city.

Both periodontists and postgraduate students in periodontology demonstrated awareness and knowledge regarding the use of botulinum toxin (BTX) as a possible treatment modality for gummy smile and its applications in the field of periodontics. The results were found to be statistically significant (Table 1).

Overall, 92.8% of participants were aware of the use of BTX for gummy smile correction (Table 1). When compared between the groups, 94.5% of periodontists and 91.2% of postgraduates were aware, indicating that periodontists had slightly higher awareness. The results were statistically significant (Table 2).

Regarding the attitude toward the use of BTX for gummy smile correction, 97.3% of participants considered BTX to be safe, and 97% were aware of gummy smile, both findings being statistically significant (Table 1). When analyzed by group, 91.2% of postgraduates and 94.5% of periodontists demonstrated positive attitude toward the use of BTX for correction of gummy smile (Table 2).

A total of 93.3% of postgraduate students and 98.4% of periodontists stated that botulinum toxin can be administered within a dental setup. About 91.9% of postgraduate students and 97.7% of periodontists agreed that BTX can be used to correct asymmetric smiles (Table 2).

The overall mean scores were 4.68±0.91 for knowledge, 4.69±0.79 for attitude, and 4.46±0.95 for practice (Table 4). When comparing postgraduates and periodontists, the difference in mean scores for knowledge, attitude, and practice were not statistically significant, with P values of 0.85, 0.52, and 0.52, respectively (Table 4).

Discussion

The main objective of this study was to assess the knowledge and awareness regarding the use of botulinum toxin (BTX) as an alternative treatment modality for gummy smile among periodontists and postgraduate students specializing in periodontics.

To the best of our knowledge, only a limited number of studies have exclusively assessed the level of knowledge and awareness among postgraduate students in periodontics and periodontists regarding the use of BTX for the management of gummy smile.

Smiling is an important aspect of nonverbal communication. There are two stages to developing a smile. In the first stage, the upper lip rises to the nasolabial fold, with the medial muscle bundles elevating the lip at the anterior teeth and the lateral muscle groups raising it at the posterior teeth, while the cheek fat provides resistance at the nasolabial fold. In the second stage, the lip is elevated superiorly by three muscle groups: the levator labii superioris, the zygomaticus major, and the superior fibers of the buccinator. Overall, a person's smile is determined by three factors: the teeth, the gums, and the lips.^1,11,12

Exposure of the gingiva when smiling, to a certain extent, contributes to a youthful and cosmetically appealing appearance. A gingival display of 1 to 2 mm during smiling is considered normal. Excessive exposure of gingiva in the maxillary arch, commonly referred to as a “gummy smile,” is considered as an undesirable and embarrassing cosmetic condition.¹³

A gummy smile may result from various conditions, including a hypermobile or short upper lip, altered passive eruption, dentoalveolar extrusion, vertical maxillary excess (VME), and gingival hyperplasia, with VME being one of the most common causes. Accurate identification of the underlying etiology is essential for effective management, as it determines the treatment plan and outcomes.¹³

Botox has recently emerged as a treatment option for gummy smile due to its simplicity, safety, low risk, reversibility, and rapid cosmetic effect. However, its effects are temporary, typically lasting 4 and 6 months, depending on muscle activity and thickness.^14,15

Botulinum toxin acts by inducing muscle paralysis through inhibition of presynaptic acetylcholine release at the neuromuscular junction. It is an effective alternative for managing gummy smiles caused by a hyperactive upper lip.¹³

Botulinum toxin is a protein produced by Clostridium botulinum, a Gram-positive, spore-forming anaerobe. BTX was approved in 1989 by the U.S. Food and Drug Administration (FDA) for therapeutic indications, including the treatment of involuntary muscle contractions such as strabismus, blepharospasm and hemifacial spasm.¹⁰

The FDA later expanded the approval of BTX to include the cosmetic treatment of glabellar frown lines. Since then, it has been widely used to reduce hyperfunctional lines associated with the muscles of facial expression.¹⁶ 

On both sides of the face, BTX infiltrates into the levator labii superioris alaque nasi (LLSAN) and levator labii superioris muscles. Typically, 4 to 6 units of BTX are injected bilaterally at three points: 2 mm lateral to the alar-facial groove, 2 mm lateral to the first injection point along the same horizontal plane, and 2 mm inferior to a point midway between the first two sites.¹³

In this study, both periodontists and postgraduate students demonstrated greater knowledge and a positive attitude toward BTX as a potential treatment modality for gummy smile and its application in periodontics.

In our study, 97% of participants were aware of gummy smile, whereas in the study conducted by Jessica et al., only 60% demonstrated awareness. Furthermore, 96.2% of participants in our study believed that gummy smile affects aesthetics, compared to 93.3% in the study by Jessica et al.¹⁷

In this study, 92.8% of participants were aware of the use of BTX for gummy smile correction. In the study conducted by Al Hamdan EM et al., most dentists were aware that BTX could be used for cosmetic purposes, with wrinkle reduction being the most frequently reported application (73.7%), followed by treatment of a gummy smile (51.0%).¹⁸ Additionally, 96.2% of participants in our study recognized botox as a cosmetic treatment. Overall, our study population showed greater awareness regarding BTX usage for gummy smile correction. Furthermore, 94.3% of participants correctly identified a lip line above the gum tissue as a high lip line, compared to 62.4% in the study by Jessica et al.¹⁷

In our study, 97.3% of participants believed that Botox is safe, including 97.8% of postgraduate students and 96.9% of periodontists. In contrast, the study by Al Hamdan EM et al., reported that only 18.9% of participants believed botulinum toxin had no side effects. Khalid AA et al. found that 50.7% of participants had knowledge regarding the side effects of dermal fillers.^18,19

In our study, 95.8% of participants, including 93.3% of postgraduate students and 98.4% of periodontists, believed that Botox can be administered within a dental setup. Al Hamdan EM et al., reported that 37.8% expressed interest in practicing botulinum toxin/dermal fillers, mostly for aesthetic dental purposes.¹⁸ Similarly, Osailan S et al., found that 70.2% supported the practice of Botox and dermal fillers by dentists, whereas Khalid AA et al. reported that only 12.5% were actively practicing it in clinics.^19,20 About 90% agreed with the use of BTX as a combination treatment for dental patients, reflecting a positive attitude towards BTX use in dental practice, which is consistent with our study finding.

Our study demonstrated a positive awareness and attitude toward the use of Botox for gummy smile correction among both study groups. However, further research is required to evaluate the practical application of BTX in dental setups, its long-term effects, and outcomes related to gummy smile management. Official training courses should be implemented to ensure the safe and legal use of BTX in dentistry.

A limitation of our study is that it included only periodontists and postgraduate students in periodontics. Future studies could expand the sample to include undergraduate students, general dental practitioners and academicians to assess the awareness, knowledge and clinical practice regarding BTX in dentistry.

Conclusion

Periodontists and postgraduate students demonstrated greater knowledge and a more positive attitude toward the use of botulinum toxin (BTX) as an alternative treatment modality for gummy smile and its application in the field of periodontics. However, further research is required to understand the use of BTX for gummy smile correction and to develop optimal attitude for diagnosis and treatment among dentists, periodontists and postgraduate students.

Conflicts of interest

There are no conflicts of interest.