A Tel Aviv dermatologist teaches dentists in a 15-hour, two-day, NIS 14,400 esthetic medicine course how to inject patients' faces from their forehead down to around the mouth with Botox toxin, as well as hyaluronic acid and collagen to "fill in lips and wrinkles," The Jerusalem Post has learned. But the Health Ministry chief of dental services warned dentists are only allowed to perform such injections only "as part of dental treatment and only around the mouth and into the lips." Dr. Michael Shohat, who is in charge of dermatology and hair removal at Clalit Esthetics, owned by the largest health fund, Clalit Health Services, advertised the course for dentists on a full page of the latest issue of the Israel Journal of Family Medicine to promote his private "Esthetic Medicine Clinic" in Tel Aviv's Rehov Weizmann. He advertised the course as a "revolution in Israeli dentistry" that offers participants "an additional medical field" and "extra income" for dentists who want to learn how to give "esthetic treatments in the field of injections to fill in facial wrinkles." The ad promises that each participant will receive a "diploma from the Institute for Professional Upgrading and Practical Training in Esthetic Medicine" signed by Shohat himself, as well as a three-injection vial of Botox and one-injection syringe of filling agent "worth NIS 3,500" plus a manual and a DVD-ROM "worth NIS 10,000." The ad notes that Shohat is a "senior specialist in dermatology" and a member of both the American Academy of Dermatology and the European Society for Dermatological Laser Treatment, with "more than 10 years experience in esthetic dermatology [who is] one of Israel's leading specialists in the field." The ad notes that participants are invited to participate in a free "injection marathon," but does not state what that involves. The advertisement also notes that Shohat's certificate is "accepted and approved by the department for professional/medical liability insurance" of the Shuki Madanes insurance company for "insurance coverage in the field of injections for filling facial wrinkles" as written in the policy. Madanes is charging participants in Shohat's course only "a few hundred dollars a year" for insurance coverage of their injecting Botox and filling agents into the faces of patients, Shohat told the Post on Sunday when this reporter called for more information. Asked about his advertised course, Shohat said that dentists in the UK, US and Europe were giving esthetic Botox injections to clients as well as using hyaluronic acid and collagen to temporarily fill in wrinkles and thicken lips. "These are all reversible. I am against using silicone injections and don't use them," he explained. Botox is a prepared form of botulin, a highly toxic protein found in swollen cans of food that is used by physicians in minute doses to treat painful muscle spasms and stop excessive sweating, as well as provide cosmetic treatment by plastic surgeons, dermatologists and other physicians to relax muscles. Dr. Shlomo Zusman, head of dental health services in the Health Ministry, told the Post that he was not aware of such courses and had not seen Shohat's ad. However, he stated clearly that while physicians are permitted to give such injections, dentists may use Botox and filling materials "only if they are directly part of dental treatment and involve only the area around the mouth and the lips." They may not inject other parts of faces for esthetic purposes, he said. Zusman said he and his office would investigate, especially with maxillofacial surgeons and other physicians who perform injections. "I hope dentists are not giving such injections in other parts of the face. They are putting themselves at risk," Zusman said, adding that so far, his office has not received complaints about Botox or filling agent injections by dentists. "Just as dentists do not do body piercing, they should not give esthetic treatment for wrinkles. It can be used only as a part of dental treatment if there is a specific indication. A dentist should deal only in dentistry," Zusman added. Asked to comment, the Clalit Health Services spokeswoman said that after an initial examination, it appears as if Shohat's use of the health fund's name and that of its esthetic medicine service "is aimed at promoting his private business and certainly not as part of his work in Clalit Esthetics. The advertising was done without permission and without our knowledge and authorization. The doctor will be called in" for examining the case, Clalit said. "Over the years, Clalit Esthetics has had a position that esthetic treatments should be given only by specialists in plastic surgery or dermatologists who specialize in esthetic medicine," the spokeswoman said. After dentists - as well as some general practitioner physicians - finish the first day of the course (on Fridays), Shohat said, "they are invited on Sunday at the end of the course to bring with them their own patients and inject them as practice, for which the patients do not pay anything." So far, some 40 to 50 people - mostly dentists but also some physicians - have participated in his courses, an average of about 10 in each. Shohat said he was the only physician there and supervised the activity. The only limits he tells dentists is that "they must not advertise that they have an esthetic clinic." Shohat said he "recommends that dentists focus on the mouth, but as Botox injections are easier to do at the top of the face, I show them how to do the forehead and then go towards the bottom and focus on the mouth." Plastic surgeons, as well as dermatologists, "don't like the competition from dentists," Shohat said. He claimed there were a handful of other courses for dentists in Israel - run by dermatologists - and that 200 out of the country's 7,500 working dentists may have already participated in them. Three years ago, a paper published in the Journal of American Academy of Dermatology quoted the US Food and Drug Administration (FDA) saying that use of Botox had resulted in 28 deaths between 1989 and 2003, though none was attributed to cosmetic use but only to medical uses. Last February, the FDA said that Botox has "been linked in some cases to adverse reactions, including respiratory failure and death, following treatment of a variety of conditions using a wide range of doses," due to its ability to spread to areas distant to the site of the injection. Possible side effects in cosmetic use include inappropriate facial expressions such as drooping eyelid, uneven smile and loss of ability to close the eye. This will wear off in around six weeks, experts say. If there is bruising from the clinician applying pressure to the injection site, it will last up to 10 days. When injecting a jaw muscle, loss of muscle function will result in a loss or reduction of power to chew solid foods. Reported adverse events from cosmetic use includes temporary headaches, focal facial paralysis, muscle weakness, flu-like syndromes and allergic reactions, it has been reported. Experts say that cosmetic Botox treatments, which cost thousands of shekels, last for a minimum of six weeks to eight months or a year. After being informed of the Shohat ad by the Post, the Israel Medical Association and the Israel Dental Association (IDA) decided to convene an unusual urgent joint meeting to discuss the subject of who may inject patients cosmetically with Botox and filling agents. The IDA added that Botox was "introduced into dentistry for treating jaw muscles. In the US, dentists inject Botox as part of their [dental work] and also during cosmetic treatments. Dentists are experienced daily in giving injections [of local anesthesia] in general. The work of maxillofacial surgeons makes it possible for them to be more skilled than other physicians. On rare occasions, when defects are created, these have to be corrected by using Botox. Courses for using Botox require permission from the Israel Medical Association's Scientific Council," the IDA statement said. Asked for his opinion of Shohat's course, Prof. Jonathan Mann, dean of the Hebrew University-Hadassah School of Dental Medicine, said that giving esthetics treatment for wrinkles "is not for dentists." But he understood the reason why some would want to take a course, as there is currently an excess of Israeli dentists, about one per 770 Israelis (second highest rate after Greece). "We really don't need any more now except for top specialists. We are training 45, and Tel Aviv University's dental school is graduating 16. The average age of Israeli dentists is 45, many of them immigrants from the former Soviet Union, so the excess will not last indefinitely," said Mann. "I wouldn't say that dentists are hungry, but some have low income, especially if they work as salaried dentists for health funds or private chains or clinics or work in areas where people can't afford to pay." The dental school dean declared: "I really don't like dentists injecting Botox and filling agents into wrinkles. I have no words to describe how I feel. This is the work of plastic surgeons and dermatologists!" Asked whether he would even consider taking such a course, a veteran Jerusalem dentist said it would be "insane. If I tell any patients that they have wrinkles, they will seek out a plastic surgeon. These cosmetic treatments are temporary, complicated and never solve the whole problem. A dentist who spends NIS 14,400 on the course will then drive his patients crazy trying to sell this expensive treatment to every other one and will make money in the end. But this is not ethical dentistry."