TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING

BOARD OF DENTISTRY

Proposed Regulation

Title of Regulation: 18VAC60-21. Regulations Governing the Practice of Dentistry (amending 18VAC60-21-350; adding 18VAC60-21-55).

Statutory Authority: § 54.1-2400 of the Code of Virginia.

Public Hearing Information:

January 29, 2026 - 10 a.m. - Department of Health Professions, 9960 Mayland Drive, Hearing Room One, Henrico, VA 23233.

Public Comment Deadline: February 13, 2026.

Agency Contact: Jamie Sacksteder, Executive Director, Board of Dentistry, 9960 Mayland Drive, Suite 300, Henrico, VA 23233, telephone (804) 367-4581, fax (804) 698-4266, or email jamie.sacksteder@dhp.virginia.gov.

Basis: Regulations of the Board of Dentistry are promulgated under the general authority of § 54.1-2400 of the Code of Virginia, which specifically states that the general powers and duties of health regulatory boards shall be to promulgate regulations that are reasonable and necessary to administer effectively the regulatory system. Section 54.1-2711.2 of the Code of Virginia requires the board to determine training requirements for the administration of botulinum toxin injections for cosmetic purposes.

Purpose: The board has been directed to determine training requirements for dentists to administer botulinum toxin injections for cosmetic purposes. To state such requirements, the board must promulgate regulations. A workgroup of stakeholders and the board felt that the training delineated in the proposed regulatory language constituted the minimum requirements necessary to ensure safety of patients and the public. The only goals of the regulatory change are to comply with legislative directive while ensuring safety of the public by requiring minimum training standards.

Substance: A new section, 18VAC60-21-55, lists the training requirements for dentists to administer botulinum toxin injections for cosmetic purposes, and 18VAC60-21-350 is amended as required by Chapter 413 of the 2023 Acts of Assembly.

Issues: The primary advantages to the public are ensuring that dentists administering botulinum toxin injections are appropriately trained. There are no disadvantages to the public. There are no primary advantages or disadvantages to the agency or the Commonwealth.

Department of Planning and Budget Economic Impact Analysis:

The Department of Planning and Budget (DPB) has analyzed the economic impact of this proposed regulation in accordance with § 2.2-4007.04 of the Code of Virginia and Executive Order 19. The analysis presented represents DPB's best estimate of the potential economic impacts as of the date of this analysis.¹

Summary of the Proposed Amendments to Regulation. Pursuant to Chapter 413 of the 2023 Acts of Assembly,² the Board of Dentistry (board) proposes to make an emergency regulation permanent establishing training requirements for dentists to administer botulinum toxin injections (Botox) for cosmetic purposes.

Background. Prior to 2023, dentists were allowed to administer Botox for dental purposes, such as assisting with treating temporomandibular joint issues. In 2023, Chapter 413 required the board (in consultation with the Board of Medicine) to amend its regulations to establish training and continuing education requirements for dentists related to the administration of Botox for cosmetic purposes. In essence, the legislation broadened dentist scope of Botox practice from oral conditions to broader cosmetic purposes (generally understood as facial and head applications). In addition, Item 301.C of the amended budget bill passed in 2023 Special Session I³ required that the regulation to implement Chapter 413 be promulgated within 280 days of its enactment. As a result, the board established an emergency regulation effective May 6, 2024.⁴ In the emergency stage, the board established a 12-hour training requirement in certain subjects for dentists to administer Botox for cosmetic purposes. Training must include a minimum of four hours of clinical in-person training on at least two live patients, and this must include post-procedure patient follow-ups. Eight of the 12-hours of training may be didactic and may be obtained online or in person. The training must be provided by a dental program or advanced dental education program accredited by the Commission on Dental Accreditation, the American Dental Association or its constituent or branch associations, or the Academy of General Dentistry. The pre-emergency regulation also allowed oral and maxillofacial surgeons to administer Botox for aesthetic or cosmetic procedures if they had a certificate to perform such procedures. Given the enactment of Chapter 413, the board also removed that certification requirement for oral and maxillofacial surgeons in the emergency regulation as under the proposal they can administer Botox with appropriate training without the need to obtain certification. Although the legislation requires initial training, it allowed but did not require the board to establish continuing education for dentists to administer Botox for cosmetic purposes; in response, the board chose not to require any continuing education. In this action, the Board proposes to make the emergency regulation permanent, without any changes from the emergency text.

Estimated Benefits and Costs. The legislation mandated that the board establish training requirements for dentists to administer Botox for cosmetic purposes, but it did not specify any aspects of such training. The board established a 12-hour training requirement at its discretion, but states that the training hours required under the emergency regulation are a minimum to ensure the health and safety of patients. Since the board is mandated to establish training and it adopted a minimal amount of training, it can be concluded that the 12-hours of training is legislatively mandated rather than being a requirement at board discretion. In that sense, any potential economic impact of the proposal is a creature of legislation rather than regulation. Also, Chapter 413 allows dentists to administer Botox for cosmetic purposes but does not require them to do so. Thus, we can reliably assume dentists who choose to obtain training would anticipate greater benefits than the training would cost. There is no concrete information on potential demand or price of such cosmetic procedures or on the cost of the training. However, the Department of Health Professions (DHP) believes that there would be little consumer demand for dentists to perform such procedures either from the dental community or their patients, though the agency is aware that at least one dentist in southwestern Virginia was interested in providing these services. However small the demand may be, allowing dentists to administer Botox for cosmetic procedures may add to the competition for the physicians that offer such procedures. Additionally, oral and maxillofacial surgeons would now be allowed to perform Botox for cosmetic purposes with the required training and without the need to obtain certification. The training is believed to be less onerous than obtaining certification for these surgeons, but there is no concrete information on the cost differences either. In summary, any potential impact should be considered stemming from legislation rather than regulation (including the potential for increased competition for physicians administering such procedures); and because the legislation allows for but does not mandate dentists to administer Botox for cosmetic purposes, we can conclude that anticipated benefits to dentists who choose to obtain training for cosmetic Botox procedures must exceed the expected costs of the training.

Businesses and Other Entities Affected. According to reports by DHP,⁵ as of June 2024, there were 7,972 dentists licensed by the Board and there are 275 oral and maxillofacial surgeons registered. No regulated entity appears to be disproportionately affected. The Code of Virginia requires DPB to assess whether an adverse impact may result from the proposed regulation.⁶ An adverse impact is indicated if there is any increase in net cost or reduction in net benefit for any entity, even if the benefits exceed the costs for all entities combined.⁷ The proposal stems from the legislation and offers an option to dentists to administer Botox, but does not mandate it. Thus, no adverse impact on account of this regulatory proposal is indicated.

Small Businesses⁸ Affected.⁹ The proposed regulatory changes conform to the 2023 legislation and do not adversely affect small businesses.

Localities¹⁰ Affected.¹¹ The proposal does not introduce costs for localities.

Projected Impact on Employment. The proposed regulatory amendments do not affect total employment as they simply conform to the mandate of the legislation.

Effects on the Use and Value of Private Property. No impact on the use and value of private property nor on real estate development costs is expected from this regulatory action.

_____________________________

¹ Section 2.2-4007.04 of the Code of Virginia requires that such economic impact analyses determine the public benefits and costs of the proposed amendments. Further the analysis should include but not be limited to: (1) the projected number of businesses or other entities to whom the proposed regulatory action would apply, (2) the identity of any localities and types of businesses or other entities particularly affected, (3) the projected number of persons and employment positions to be affected, (4) the projected costs to affected businesses or entities to implement or comply with the regulation, and (5) the impact on the use and value of private property.

² https://legacylis.virginia.gov/cgi-bin/legp604.exe?231+ful+CHAP0413.

³ https://budget.lis.virginia.gov/item/2023/2/HB6001/Chapter/1/301/.

⁴ https://townhall.virginia.gov/L/ViewStage.cfm?stageid=10203.

⁵ https://www.dhp.virginia.gov/about/stats/2024Q4/04CurrentLicenseCountQ4FY2024.pdf.

⁶ Pursuant to § 2.2-4007.04 D: In the event this economic impact analysis reveals that the proposed regulation would have an adverse economic impact on businesses or would impose a significant adverse economic impact on a locality, business, or entity particularly affected, the Department of Planning and Budget shall advise the Joint Commission on Administrative Rules, the House Committee on Appropriations, and the Senate Committee on Finance. Statute does not define "adverse impact," state whether only Virginia entities should be considered, nor indicate whether an adverse impact results from regulatory requirements mandated by legislation.

⁷ Statute does not define "adverse impact," state whether only Virginia entities should be considered, nor indicate whether an adverse impact results from regulatory requirements mandated by legislation. As a result, DPB has adopted a definition of adverse impact that assesses changes in net costs and benefits for each affected Virginia entity that directly results from discretionary changes to the regulation.

⁸ Pursuant to § 2.2-4007.04, small business is defined as "a business entity, including its affiliates, that (i) is independently owned and operated and (ii) employs fewer than 500 full-time employees or has gross annual sales of less than $6 million."

⁹ If the proposed regulatory action may have an adverse effect on small businesses, § 2.2-4007.04 requires that such economic impact analyses include: (1) an identification and estimate of the number of small businesses subject to the proposed regulation, (2) the projected reporting, recordkeeping, and other administrative costs required for small businesses to comply with the proposed regulation, including the type of professional skills necessary for preparing required reports and other documents, (3) a statement of the probable effect of the proposed regulation on affected small businesses, and (4) a description of any less intrusive or less costly alternative methods of achieving the purpose of the proposed regulation. Additionally, pursuant to § 2.2-4007.1 of the Code of Virginia, if there is a finding that a proposed regulation may have an adverse impact on small business, the Joint Commission on Administrative Rules shall be notified.

¹⁰ "Locality" can refer to either local governments or the locations in the Commonwealth where the activities relevant to the regulatory change are most likely to occur.

¹¹ Section 2.2-4007.04 defines "particularly affected" as bearing disproportionate material impact.

Agency Response to Economic Impact Analysis: The Board of Dentistry concurs with the economic impact analysis prepared by the Department of Planning and Budget.

Summary:

Pursuant to Chapter 413 of the 2023 Acts of Assembly, the proposed amendments (i) create training requirements for dentists to administer botulinum toxin injections for cosmetic purposes and (ii) provide for oral and maxillofacial surgeons to administer dermal filler.

18VAC60-21-55. Training requirements for administration of botulinum toxin injections for cosmetic purposes.

A. A dentist may possess and administer botulinum toxin injections for cosmetic purposes provided that the dentist has completed 12 hours of training in the subjects listed in subsection C of this section. Training must include a minimum of four hours of clinical, in-person training on at least two live patients, which shall include patient follow-up post-procedure. Eight of the 12 hours of training may be didactic and may be obtained online or in person.

B. To satisfy the requirements of this section, training must be provided by a dental program or advanced dental education program accredited by CODA, the ADA or its constituent or branch associations, or the Academy of General Dentistry.

C. Training to possess and administer botulinum toxin injections for cosmetic purposes shall include the following subjects:

1. Assessing patients for use of botulinum toxin injections;

2. Screening of patient expectations and psychological motivations;

3. Diagnosis, planning, and treatment;

4. Informed consent, including off-label use of botulinum toxins;

5. Anatomy and neurophysiology of the head and neck;

6. Indications and contraindications for the use of botulinum toxin injections, including off-label and approved product uses;

7. Pharmacology of neurotoxins and botulinum toxins;

8. Safety and risks associated with use of botulinum toxins, including the recognition and management of adverse reactions and complications;

9. Preparation and administration of botulinum toxins; and

10. Evaluation of patient outcomes.

18VAC60-21-350. Certification to perform cosmetic procedures; applicability.

A. In order for an oral and maxillofacial surgeon to perform aesthetic or cosmetic procedures, he the oral and maxillofacial surgeon shall be certified by the board pursuant to § 54.1-2709.1 of the Code. Such certification shall only entitle the licensee to perform procedures above the clavicle or within the head and neck region of the body.

B. Based on the applicant's education, training, and experience, certification may be granted to perform the following procedures for cosmetic treatment:

1. Rhinoplasty and other treatment of the nose;

2. Blepharoplasty and other treatment of the eyelid;

3. Rhytidectomy and other treatment of facial skin wrinkles and sagging;

4. Submental liposuction and other procedures to remove fat;

5. Laser resurfacing or dermabrasion and other procedures to remove facial skin irregularities;

6. Browlift (either open or endoscopic technique) and other procedures to remove furrows and sagging skin on the upper eyelid or forehead;

7. Platysmal muscle plication and other procedures to correct the angle between the chin and neck;

8. Otoplasty and other procedures to change the appearance of the ear; and

9. Application of injectable medication or material for the purpose of treating extra-oral cosmetic conditions. Administration of dermal filler.