The Dentist Hypocrasy

Dentists in several states are petitioning to have non dentists prohibited from performing teeth whitening procedures. On one hand, I can understand this.  Teeth whitening is clearly a dental procedure. The procedure is perfomed in many spas and in physician offices as well.

The American Dental Association (ADA) is petitioning states to enact legislation banning the procedure from non-dental offices. They have been very successful thus far. Twelve states have already enacted legislation limiting the procedures to dental opffices. The legitimate justification for the regulation is the incidence of teeth sensitivity, gum irritation and in extreme cases, trauma to the teeth, gum and enamel. Most of theses problems are transient and the incidence of a true problem is rare.

Here is the hypocrasy: dentists are routinely performing non-dental procedures such as derma fillers (Resylane, Juvederm, etc) and Botox Cosmetic. They are performing laser treatments and hair removal services as well.  The incidence of complication in these procedures is gretaer than in teeth whitenting and the potential side effects are worse. Yet, they are pushing legislation to protect their turf and criticising others, such as dermatologists, who are legitimately protecting their turf.

In my opinion, dentists should be doing teeth whitening and it should not be provided in a spa setting.  However, physicians should be able to perform this procedure.

However, I also believe that dentists should not be doing aesthetic laser, dermal filler and wrinkle relaxers. It is outside the scope of their license, experience and training. I am not talking about maxillo facial doctors and other M.D.'s that practice medicine in and around the mouth and face.  I am talking about true dentists.

I just returned from a business trip to New York and I was appalled at some ads by dentists. Not only did they claim to be "experts" in aesthetic medicine, and not only are they doing these procedures, BUT they are claiming that dentists are the true experts in the delivery of dermal fillers, Botox Cosmetic and other procedures on the face!!! Sorry, guys (and ladies) almost everything that you are doing is dermatology...don't take my word for it...ask the FDA and the ABMS. You are practicing outside the scope of your license!!

Corporate Practice of Medicine Doctrine

This is also known as the “non-corporate practice of medicine doctrine”. Almost every day, I hear some client mention that a consultant built a business model for them and I quickly discover that this well-standing and well-intentioned doctrine has been violated.  The purpose of the doctrine was to prevent non-physicians from controlling or altering our health care delivery system.

 Forty-five out of fifty states prohibit non physicians from owning or operating medical facilities. This includes medical spas or medical practices that engage exclusively in cosmetic, medical procedures.  It may also include laser hair removal centers (this is a complicated situation and will be covered in other blogs). There are limited exclusions to this (such as HMO's).  I do not understand why so many facilities ignore this well-standing premise of law.  In particular, nurses seem to feel that they can own a medical facility and provide treatments since they are fee for service or cosmetic in nature.  Many estheticians seem to believe this as well.  This is a serious and long-standing doctrine of law.  Ignoring it can cause you to lose your license from the state and criminal fines and penalties may be imposed.

The short version of the story is that only physicians can own and operate a medical facility in the forty five out of fifty states (the notable exception is Florida).  Nurses must be employed by such a facility or otherwise contracted with them.  A medical director or supervisor is not enough to enable a nurse to own or operate a medical spa. A medical director or supervisor may not be enough to enable the non-physician to operate a laser, inject dermal fillers (Restylane, Juvederm, etc) or wrinkle relaxers such as Botox Cosmetic.  The reason for this is that lay people… including attorneys, PhD’s and every non-physician…cannot interfere or alter a physician’s “independent medical judgment”. They are to be free to practice medicine in the manner that they deem appropriate outside the business or financial considerations of the corporate (and arguably, governmental) control.

There are legal means in which a nurse and physician may own a medical spa together.  A medical spa is considered to be a medical facility and it must be governed accordingly.

Posted by Paddy Deighan

Interesting Question Asked of Me....

I recently wrote a blog about laser hair removal and how it relates to the practice of medicine.  I received feedback about  this blog and I was asked..."if laser hair removal is not the practice of medicine, is laser (and light based) tattoo removal the practice of medicne".

This actually has the same answer...light based tattoo removal is not the diagnosis or treatment of a medical ciondition, so it is not the practice of medicine.  However, the light sources utilized ARE medical devices and they are federally classified.  Tattoo removal can be achieved with lasers or IPL (Intense Pulsed Light) sources.   A laser is a Class IIIb or Class IV medical device and must be owned and operated by a physician (procedures may be delegated to non - physician employees. An IPL is a Class II device and should be utilized by a physician or an appopriate employee of the physician.

Many states have regulations that can expand or limit the use of these devices.  It must be noted that whenever state and federal laws address the same issue, the stricter of the two will prevail.  Seek th eguidance of a health care lawyer whi is well versed in this issue...admittedly we are rare!

New Jersey Rules Illustrate Why We Need Restrictions on Cosmetic Procedures

The New Jersey State Board of Dentistry promulgated rules that restrict the delivery of cosmetic procedures by dentists in the State.  New Jersey is known as a "bell weather" state - meaning that other states typically follow legal precedent started in New Jersey.

The new rules state that dentists can do injectable pharmacologics only in the perio-oral area — the gums, cheeks, jaws, lips, oral cavity and associated tissues.  This makes sense as these areas are consistent with the training and experience of dentists.  Predictably, many dentists are outraged by this but the bottom line is that the use of injectables is outside the scope of their license and training.  Procedures such as the wrinkle relaxer Botox Cosmetic, and the dermal fillers such as Juvederm and Restlyane are either prescription (Botox Cosmetic) or a medical device and it is arguably appropriate to limit the use to medical professionals and not dentists.

The new rules are a  bit vague and their are categories of "dentists" that are exempt. For example, maxi lo - facial physicians and oral surgeons are technically medical doctors and not dentists. The term "associated tissue" is also vague.

Many dentists consider the forehead to be an "associated tissue," which would make forehead procedures legal for dentists. Some local dentists in New Jersey, citing their aptitude in the workings of the facial muscles and nerves, say they are more than qualified to offer the treatments.  However, this appears to be a stretch. The "associated tissue" area would preclude the forehead, said Jeff Lamm, spokesman for the Division of Consumer Affairs, which oversees the board of dentistry.

"These are practices of medicine and should be performed by physicians," said Dr. Bruce Brod, a dermatologist and member of the American Academy of Dermatology Association. "This isn't just about doing the procedure but also about making sure there are channels to protect patients if there are complications.

I agree with this new rule since a line must be drawn in the delivery of cosmetic medical procedures and dentists are on the wrong side of the line. However, this rule also illustrates that these procedures are cosmetic medical procedures and they should only b e delivered in medical settings and provided by medical providers.

I feel that regulations should go a step further and regulate the manufacturers such as Allergan (Botox Cosmetic).  There needs to be restrictions on who they can SELL the products to....

I Have to Get This Off of My Chest....

OK, this really doesn't have anything to do with medical spas or health care...but they are affected by economic irresponsibility...sooooo, I am speaking at a conference in Orlando...for the record, discussing Autologous Adipose Derived Stem Cells vs. Pluripotent stem cells in muskulo-skeletal deficiencies....you asked!

Anyway, while minding my own business in The Disney Dolphin Hotel, a GROSSLY overrated resort, I find myself watching the news... A story comes on about a state senator, otherwise now known as the colossal jackass of politics. Aforementioned colossal jackass of politics proposes legislation that enables ILLEGAL immigrants to receive a college education in Florida under the in-state tuition program.  His rationale??  THIS IS A QUOTE, "we provided them a free education from K-12, so why not college too"?? WHAAAAAT???

So let me see if I have this straight, an illegal immigrant can pay $10,000 per year to attend college in Florida, but a young man or young lady from Georgia would pay $28,000??

Want more?? I did some research...it costs about $25,000 for each student to attend a Florida university.  So, TAXPAYERS will subsidize $15,000 per ILLEGAL IMMIGRANT to attend a university.

Want STILL more?? The illegals earned the money to pay the $10,000 ILLEGALLY and did not pay taxes on it!!!!!!! AND they qualify for financial aid!!!!!!!!!!!!!

WHERE DOES IT END???  And there are some of you that believe that the government can fix real estate, banking, and the auto industry???...they couldn't fix a flat............



The collossal jackass of politics has a name...other than mud....it is Senator Siplan

Update from the 19th Annual World Congress on Anti-Aging and Aesthetic Medicine

Here is an update from the 19th Annual World Conference on Anti Aging and Aesthetic Medicine in Orlando. There is deservedly a lot of talk about two emerging trends..stem cell applications and hormone therapy and conditions.  There is no question that stem cells are the future of medicine and will provide tremendous benefit in out lifetimes.  Stem cells currently have over 220 applications in the human genome and additional applications in the veterinary world. Science is evolving rapidly and new treatments are already being offered and many more in the not to distant future.


We are also learning more and more about the endocrine system and the inter-relationship of hormones.  We are also learning more about the problems that hormonal imbalance can cause. This is a complicated field and there is a lot more to learn.


The challenge for medical providers will be to separate false claims from reality in these two fields.  I have heard some supportable claims at the conference as well as other claims that are....for lack of a better term....NOT supportable by the science!!!

Are Laser Hair Removal Centers Medical Practices???

There have been waves of laser hair removal centers since the first FDA cleared laser was introduced for permanent reduction of hair (1995).  Centers open and close with regularity. It is difficult to maintain a profitable business if it is solely a laser hair removal business.

Eventually, those that open the laser hair removal centers realize this and expand their product and service. Frequently, this is not legally supportable.

The long and short of the situation is that hair removal is not considered to be the practice of medicine.  There are dozens of therapies to remove hair dating back to the ancient Egyptians. Sugaring, waxing, electrolysis, needle free electrolysis, chemical de-epilation are all effective but none are permanent.  The only permanent treatment is laser.

Their are several types of laser for hair removal and a center should have at least three in order to treat the most patients in the most effective way.  This is because of different skin type (color), different hair color and the location of the body.  So, it is not as easy as leasing a laser and opening a location.

Even though laser hair removal is not a medical procedure, the devices are MEDICAL devices. It is unlawful for non-physicians to own or operate the lasers because they are medical devices.  you would never know this if you attend a spa expo and see the laser companies falling over themselves to sell a laser to a non-physician. As I have been known to say, any laser company would sell a laser to my dog Stoli if he could pony up the money!! The laser companies invariably claim to have a letter from a "guy" that indicates that it is acceptable to sell a medical device to a non-physician.

there are some light based devices that are a lower class of ,medical device that can be utilized and owned by non-physicians. These are non effective and low power.

Non physicians can own and operate laser hair removal centers, but care must be made in the formation and implementation of the business plan. As with everything, there is a right way and a wrong way...but the penalties for doing it the wrong way can lead to substantial fines and penalties and loss of professional license (cosmetologist, nursing etc).