DR. ROB KLAICH MARKS THE SPOTS ON CHRISTINE VANDERVORT’S FACE THAT HE’LL INJECT WITH BOTOX | PHOTO BY GRANT SEGALL

“Give me that angry face,” Dr. Rob Klaich tells his patient, Christine Vandervort, at his Cranberry Dental Studio.

Vandervort tries to turn her smile into a scowl. A couple of fine wrinkles crease her 36-year-old face. The dentist leans over her chair and pencils some amber dots on them.

Then he says, “Give me a look of surprise.” New wrinkles appear, and he draws dots.

Plying a slender needle, Klaich injects the 15 spots with Botox. One bleeds for a moment. They all swell a little. But Vandervort never winces.

A couple days later, she says that the shots didn’t hurt, the spots faded by the time she got home, and her skin already looks smoother — a good thing for “the squinting season, when Pittsburgh actually has sunshine,” she says.

Such cosmetic treatments are becoming more common at the place where patients typically go to get cavities filled or teeth cleaned. In fact, more than an estimated 30,000 dentists across the U.S. have been trained to administer Botox treatments for everything from smoothing wrinkles to addressing dental issues, says Dr. Louis Malcmacher, a general dentist based outside of Cleveland who is president of the American Academy of Facial Esthetics. He believes dentists give far more of these treatments than dermatologists and plastic surgeons in the U.S.

PHOTO BY HUCK BEARD

Dr. Andy Shieh of the PGH Smile Boutique in Warrendale says these minimally invasive treatments make sense in dental offices. Dental schools teach the anatomy of the full head and neck, he says. “I look at the whole picture.” Besides, dentists say patients tend to see them more often than other specialists and build more rapport with them.

Patient Rania Sakmar switched to Dr. Shieh from a plastic surgeon. She says the surgeon’s treatments took longer and hurt more, even with anesthetic cream. With Dr. Shieh, she skips the anesthetic and gets treated in 20 minutes. Other dental patients say they skip it, too, and get treated about as fast.

In 1989, the FDA began approving Botox and other brands of medicines containing botulinum toxin to treat conditions such as crossed eyes, excess sweating, chronic migraines, wrinkles on the forehead, wrinkles between the eyebrows and a few other conditions. Derived from bacteria, it’s the same toxin responsible for botulism, a type of food poisoning. The toxin blocks nerve signals to muscles. But practitioners give much smaller amounts, more localized.

“We’re not freezing the muscles,” says Dr. Alexandra Masek of Pittsburgh’s Atlas Dental Specialists, based Downtown, who has been giving such treatments for two years. “We just relax them.”

There are several specific dental conditions in which dentists say Botox can help as well, such as easing the grinding or clenching of teeth (known as bruxism) — which can lead to jaw pain — and calming the appearance of “gummy smiles,” in which a high lip line exposes the top of the gums. The FDA has not specifically approved Botox for these uses, but they are prescribed “off-label,” a common and legal use for FDA-approved drugs.

Alan Karelitz of Plum is among thousands of people who grind their teeth. He used to grind so hard, he wrecked his teeth and implants. But he’s eased up thanks to Botox in the jaw from Dr. Brian Klaich, Rob’s brother and dental partner in Cranberry.

“It’s cheap if it prevents me from breaking something,” he says.

Local patients and dentists say that each Botox treatment ranges from $300 to more than $2,000, depending upon the condition. Insurance seldom covers it.

The pandemic slowed treatments in recent years — but may be spurring them now. Rob Klaich says the extra stresses of dealing with the pandemic seems to be worsening teeth clenching, grinding and damage among some patients. Dr. Jeffrey Gusenoff, a UPMC plastic surgeon, says people’s heavy use of Zoom and other videoconferencing platforms has them turning to cosmetic treatments to improve their close-ups.

Gusenoff is leery, though, of skin treatments administered by dentists. “I go to the dentist for my teeth,” he says.

A 2020 report from Polish researchers in the journal Advances in Dermatology and Allergology says, “Treatment with botulinum toxin is widely viewed as safe, effective and largely devoid of serious side effects.” With millions of injections administered a year, it’s the most common cosmetic procedure performed worldwide.

In 2020, practitioners bought $3.2 billion of botulinum toxin across the globe, according to Fortune Business Insights. That is expected to grow to $5.68 billion by 2028.

Still, practitioners say consumers should proceed with caution and ask questions. For one thing, the treatments are costly, and the FDA says the benefits tend to last just three months.

Experts advise consumers to ask about a practitioner’s training and experience with botulinum toxin. Also, a patient should ask the same questions as for any other treatment — the benefits, risks, after-care, duration, cost and more. Disclose other medicines and conditions. For example, botulinum toxin has not been proven safe for pregnant women or for those who are breast-feeding.

The medicine’s side effects can range from droopy eyelids and stiff expressions to swelling, pain, shock and, in rare cases, death. The Poland study says therapeutic doses tend to be four times bigger than cosmetic ones and serious complications 33 times likelier.

Botox is considered better for treating wrinkles caused by expressions rather than by sun or gravity, and better for preventing wrinkles or treating relatively new ones than older, deeper ones. The other wrinkles may respond better to fillers.

Botulinum toxin can also be overdone. Singer Brian McFadden said it made him look “like a melted candle.” For jaw problems, a 2019 study in the British Dental Journal says the medicine “should certainly be considered but due to financial implications and possible side effects, it seems appropriate that conservative options, such as self-management with explanation and physical therapies, should be exhausted first.”

Some dentists say that botulinum toxin may be too quick of a fix for sore jaws. “You are basically just treating the symptoms by masking the pain,” says the website of Wexford’s Dr. Alexandra George, a neuromuscular dentist. “Adjusting the jaw and healing the pain is a better option.”

But Rob Klaich says relaxed muscles often need fewer and smaller doses over time. And Dr. Alison King of Bittner King Dental in O’Hara says she stopped treatment of a patient who stopped needing it.

Gusenoff, the Pitt plastic surgeon, also says, “Your provider should make it clear [use of Botox for jaw problems or gummy smiles] is off-label.” But some dentists say they don’t do so with botulinum toxin, because studies support those uses. They just make the usual disclosures as for any on-label treatments.

PHOTO: SHUTTERSTOCK

“If you have concerns, start small,” says Rob Klaich about the use of Botox. Treat one area first and, if you like the results, try others.

Dental and medical students don’t study botulinum toxin. Practitioners train later and consider it crucial; they blame most side effects on poor techniques.

The training comes from organizations such as Malcmacher’s academy or from Empire Medical Training, based in Fort Lauderdale, Florida. Empire’s basic course takes eight hours and includes practice with live patients. Malcmacher’s takes 30 hours and covers several other kinds of injections as well, such as dermal fillers, again with live practice.

Different states have different rules regarding Botox, and some have none: The Pennsylvania State Board of Dentistry, for example, does not have any specific rules governing the use of botulinum toxin in dental offices. For now, the board’s Dr. Brice Arndt says the medicine should be given only by dentists, not their assistants, and to parts of the head they normally treat.

A board spokeswoman said she knew of no disciplinary actions about Botox.

Overall, Arndt says, “It’s not going to be a panacea. If you have structural issues, you can’t correct those by using Botox. There are limitations, and there need to be expectations.”

Grant Segall is a national prize-winning reporter who has written for The Washington Post, Cleveland Plain Dealer, Philadelphia Magazine, Time, Reuters, Science, Oxford University Press and other outlets.