GLP-1 receptor agonists -- the class of medications driving dramatic weight-loss results for millions of patients -- are reshaping far more than waistlines. As patients lose significant weight in compressed time frames, the face changes too: Volume diminishes; skin laxity increases; and the relationship between teeth, lips, and facial contours shifts in ways that can complicate aesthetic treatment planning considerably.
For smile design in particular, those changes introduce a moving target that requires patience, sequencing, and a clear clinical framework. In this Q&A, Dr. Robert Kerstein, DMD, shares his protocol for navigating GLP-1 patients through the aesthetic dental workflow, from initial consultation to definitive restoration.
DrBicuspid: What aesthetic changes might you observe in patients who lose significant weight on GLP-1 drugs?
Dr. Kerstein: Cheeks typically thin, and the lips may lie more flat onto the teeth, as the general GLP-1 weight loss aesthetic change is from patients appearing “aged,” which results from skinfolds and lines that appear after rapid weight loss, resulting in a thinner facial profile.
This occurs because the facial skin was stretched and lost some elasticity because there were longstanding underlying fat stores. These skinfolds may require the creative use of fillers to plump up the skin volume around the lips and in the cheeks.
In some patients, these folds can be addressed with plastic surgery. It also may help to choose a less than “white-white” tooth shade, which can really make a difference in matching a beautiful new smile to someone’s skin contours, providing improved tooth brightness that’s appropriate for the skin’s appearance changes.
How might those changes introduce unexpected considerations or challenges in treatment planning?
Visible face and smile changes with GLP-1 medications generally become noticeable after four to six weeks, with more defined changes often occurring at eight to 12 weeks when a patient drops 10% to 15% of their body weight. Patients tend to report noticing facial slimness after a loss of 15 to 20 pounds.
Treatment planning then depends on where the patient is in their drug use time frame. I advise not doing definitive smile design restorations until any GLP-1-induced facial changes have occurred. The patient can certainly bleach their teeth during this time to prepare their teeth to receive new restorations. Then after three to four months of GLP-1 use, a more definitive smile design can be treatment-planned, and a provisional smile restoration can be placed.
Beyond four months of GLP-1 use, once any photographically-documented facial changes have subsided, indicating there is skin contour, lip line, and cheek volume stability, the final smile design can be definitively treatment-planned.
At what point in a patient’s weight-loss journey would you anticipate facial changes stabilizing enough to proceed with irreversible restorative work?
Beyond five months from initial GLP-1 use, the major facial changes would have likely occurred, at which point a more definitive smile design can be considered for planning.
How could GLP-1-related dry mouth influence clinical decision-making -- for example, in terms of caries risk, soft-tissue health, or material/adhesive performance?
It's very important the GLP-1 patient supplement any dry mouth they are experiencing with artificial saliva, which would be used throughout the day and especially before bedtime.
It is also critical the patient perform exceptional home care, as dry mouth can quickly result in carious lesions. Therefore, flossing and brushing after each meal is imperative, as is performing home care right before bedtime, after which a definitive artificial saliva application should be administered. During sleep, bacteria tend to proliferate and colonize in the warm oral environment and are likely to initiate tooth decay in a dry mouth.
In a scenario where a patient’s facial structure continues changing during treatment, how might an initial smile design need to be adjusted, and how would you approach that?
Dr. Robert Kerstein.
If a patient is just starting on GLP-1 and plans on a long course of drug use to help them lose significant weight, then an initial provisional smile design can be attempted with either direct composite bonding or using a stronger provisional restoration (like an indirect lab-created composite restoration). Both provisionals can be modified over time as the continuing GLP-1 use alters the facial skin and lip anatomy.
Patients should also consistently hydrate and eat a protein-rich diet that helps maintain skin health during weight loss. They also can apply skin products that help maintain collagen.
Another significant consideration is that if long-term smile provisionalization is required -- because the patient plans on losing significant weight from continued GLP-1 use -- a long-term provisional smile restoration should be placed and refined with the T-Scan 10 Novus technology by Tekscan to control the occlusal forces on the temporary restoration.
This technology helps preserve any lengthened incisal edges and new guidance inclines resulting from tooth length changes that create a better smile. This is especially needed in direct-bonded composite smile provisionals, which are weak and can easily chip.
Articulating paper ink marks cannot reliably control occlusal forces; therefore, using the T-Scan 10 can better control occlusal forces to help maintain the provisional restoration during GLP-1 use. The T-Scan has been shown in studies to reduce mechanical complications, so its use minimizes unwanted composite fractures and reduces time-consuming emergency repair visits while the patient waits to see the smile anatomy change as their fat loss progresses.
How should treatment planning differ for patients who are actively losing weight vs. those who have plateaued?
Because facial fat loss significantly alters the "frame" of the smile, shifting from a dental aesthetic approach to a comprehensive dentofacial approach is beneficial. When facial volume decreases, teeth often appear too prominent, smile lines can deepen, and the lower face may sag.
With less facial volume, as was pointed out earlier, excessive tooth display can appear “aged,” so treatment planning should employ conservative tooth length increases. The smile design plan should consider dermatological augmentation with fillers for cheek and lip volume restoration, and using collagen stimulators to improve skin laxity.
When fat loss is an ongoing weight loss intervention, definitive treatment should be planned after the patient’s weight has stabilized. Alternatively, with rapid weight loss, a phased approach with provisional smile design restorations can be very helpful rather than performing a single major intervention too early in the patient’s weight loss progression.
Are there restorative options you might favor or avoid for these patients due to GLP-1-related factors?
In a smile design that requires a longer term of provisionalization to wait for any weight loss-induced facial appearance changes to subside, employing a multiunit, indirectly fabricated, composite restoration that is bonded into place is a wise, strength-improving, interim restoration choice to employ rather than using a direct-bonded composite as the provisional material.
What role should photography and digital smile design play in setting expectations for this population, and where might these tools fall short?
The treating clinician can take “standardized photographs.” (Each repeated view is taken with the same camera settings, flash settings, and shot from the same distance to the patient’s face.) These images help the clinician track time-based changes in the smile, the nose, the lip line, and the skin contours while fat loss progresses.
Once several months of clinical photographs document that the smile, lip, cheek, and facial anatomy remain unchanged, then the aesthetic shapes of the teeth can be finalized to match the weight loss-induced smile contours.
What guidance would you offer to a general dentist who is encountering these patients without an established protocol?
The simplest guidance is to be patient and wait (four months of GLP-1 use at a minimum) for the medication to lessen facial fat stores. In this way, the smile design can begin when the facial changes are mostly complete.
And it’s important to photographically document that facial changes have remained stable for a few more months before moving forward with dermal filler use, any plastic surgery intervention, and finalizing the aesthetic tooth shapes and color selection.
Where should future research focus -- what unanswered questions about GLP-1 medications and aesthetic dentistry would be the most important to explore?
Research should try to precisely define the actual time frame that GLP-1 use changes facial anatomy and from there, how long is needed after the facial changes appear stable that a smile design can be reliably undertaken. Additional important research areas would be when in the weight loss time continuum should dermal fillers or plastic surgery be implemented before making the final dental restorations.
Dr. Robert B. Kerstein is a nationally recognized prosthodontist, educator, and researcher whose career has helped shape the field of digital occlusion and bite analysis. Kerstein is a leading authority in computerized occlusal analysis. His research has been published widely in respected dental journals, and he has edited nine research volumes on the subject. His early work with the original T-Scan technology in 1984, along with his continued study of every generation through today’s T-Scan 10 Novus system, has supported his broader mission of advancing more precise, predictable, and patient-centered bite treatment in everyday dental care.
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