Body Dysmorphic Disorder and Cosmetic Dentistry Dysmorphic Disorder and Cosmetic Dentistry Diagnostic, ... such as tooth color, ... Body Dysmorphic Disorder and Cosmetic Dentistry

Continuing Education

Body Dysmorphic Disorderand Cosmetic Dentistry

Diagnostic, Management, and Ethical Issues

Authored by Willie J. Winfree, DDS, MPA; Leo E. Rouse, DDS; and

Ronald S. Brown, DDS, MS

Course Number: 171

Upon successful completion of this CE activity 2 CE credit hours may be awarded

A Peer-Reviewed CE Activity by

Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of

specific product names does not infer endorsement by Dentistry Today. Information contained in CE articles and

courses is not a substitute for sound clinical judgment and accepted standards of care. Participants are urged to

contact their state dental boards for continuing education requirements.

Dentistry Today, Inc, is an ADA CERP Recognized Provider. ADA CERP isa service of the American Dental Association to assist dental professionalsin indentifying quality providers of continuing dental education. ADA CERPdoes not approve or endorse individual courses or instructors, nor does itimply acceptance of credit hours by boards of dentistry. Concerns orcomplaints about a CE provider may be directed to the provider or to ADA CERP at ada.org/goto/cerp.

Approved PACE Program ProviderFAGD/MAGD Credit Approval doesnot imply acceptance by a state orprovincial board of dentistry orAGD endorsement. June 1, 2012 toMay 31, 2015 AGD PACE approvalnumber: 309062

LEARNING OBJECTIVESAfter participating in this CE activity, the individual will learn: • The definition and diagnosis of body dysmorphicdisorder (BDD).

• Clinical and ethical considerations related to BDD.

ABOUT THE AUTHORSDr. Winfree is assistant professor in the department of clinical dentistry atHoward University College of Dentistry inWashington, DC. He can be reached viathe e-mail address [email protected].

Disclosure: Dr. Winfree reports no disclosures.

Dr. Rouse is dean and clinical professorat Howard University College ofDentistry, Washington, DC. He is a past president of the American DentalEducation Association. He can bereached at [email protected].

Disclosure: Dr. Rouse reports no disclosures.

Dr. Brown is a professor in thedepartment of clinical dentistry atHoward University College of Dentistry,and clinical associate professor in thedepartment of otolaryngology at George -town University Medical Center, both in

Washington, DC. He can be reached via e-mail [email protected].

Disclosure: Dr. Brown reports no disclosures.

INTRODUCTIONThe objective of this article is to discuss the diagnosis ofbody dysmorphic disorder (BDD) (which is also known asdysmorphophobia) and how this disorder relates to clinicaldentistry. It is a relatively common condition, although anunder-recognized psychiatric disorder that has beendescribed for more than 100 years and re ported around theworld.1 It often presents to nonpsychiatric physicians and todentists, and particularly to clinicians with cosmetic practices.Although the presenting symptoms may not appear to beserious, in more severe cases, individuals with BDD may beunable to work, socialize, or leave their homes, and suicide issometimes a complication.1 These patients tend to beparticularly challenging with regard to diagnosis and patientmanagement for both physicians and dentists.2-5

BDD is included as a separate diagnosis in theDiagnostic and Statistical Manual of Mental Disorders,Fourth Edition, psychiatric diagnostic manual. “Bodydysmorphic disorder consists of a preoccupation withimagined defect in appearance; if a slight physical anomaly ispresent, the person’s concern is markedly excessive. Thepreoccupation causes clinically significant distress orimpairment in social, occupational, or other important areas offunctioning.”1 Leone et al6 reported such diagnostic criteria as:(1) Preoccupa tion with an imagined defect in appearance—if aslight physical anomaly is present, the person’s concern ismarkedly excessive; (2) The preoccupation causes clinicallysignificant distress or impairment in social, occupational, orother important areas of functioning; and (3) Thepreoccupation is not better accounted for by another mentaldisorder (eg, dissatisfaction with body shape and size inanorexia nervosa).

Naini and Gill4 reported that one of the most commonareas of concern with regard to BDD was a preoccupationwith the dentofacial region. They4 stated that up to 20% ofpatients diagnosed with BDD expressed specific concernsregarding dental appearance. They4 noted that BDD patientsoften request multiple cosmetic procedures but remainunsatisfied with the results. De Jongh et al7 evaluated 906random subjects with regard to preoccupation with one’sappearance and reported that 70 (8%) patients werepreoccupied with a defect in their appearance and that 13(1.5%) satisfied all the criteria for this disorder. BDD


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Body Dysmorphic Disorderand Cosmetic DentistryDiagnostic, Management, and Ethical Issues

Effective Date: 3/1/2014 Expiration Date: 3/1/2017

prevalence studies of the generalpublic range between 0.7% to 3%.8

However, as expected, thepercentage of pa tients seekingcosmetic care is considerablyhigher.9 Vulink et al10 reported thatout of 160 patients seekingcosmetic orthognathic oral andmaxillofacial surgery, 16 (10%)were identified with a diagnosis ofBDD. Hepburn and Cunningham11

surveyed 70 subjects from thegeneral public and reported anincidence of BDD of 2.86%,compared to a survey of 40subjects seeking orthodontic carewith a BDD incidence of 7.5%.Ishigooka et al12 reported that 198(47.7%) out of 415 patientsseeking cosmetic surgery werefound to have mental disorders andespecially BDD (33 out of 198, or16.7%), according to the WHO’sInternational Classifi cation of Diseases (tenth revision) withregard to psychiatric diagnoses.

Herren et al2 described a case regarding a young womanoverly concerned with tooth whiteness. They2 noted thatthere are many individuals in our society overly concernedwith appearance and that a number of these individualssuffer from BDD. Individuals with BDD sometimes determinethat they must adjust their appearance to mimic that ofcelebrities and become preoccupied with certain aspects ofphysical appearance, such as the look of their teeth. Herrenet al2 reported that BDD patients seeking dental caredemonstrated particular behaviors which included: (1)distress over minor flaws, such as tooth color, alignment,size, and/or shape; (2) difficulty in functioning because of anobsession with a minor flaw; (3) attempting to cover up a flaw;(4) excessive behavior regarding a flaw; (5) belief that othersare treating them differently because of the perceived flaw;(6) unjustified dissatisfaction with other dental treatment; and(7) excessive request for unnecessary dental procedures. Itis important for cosmetic dentists to consider psychiatric

referral for such patients. The Commission on Dental Accreditation13 defines

special needs patients as those “whose medical, physical,psychological, or social situations make it necessary toconsider a wide range of assessment and care options inorder to provide dental treatment. These individuals include,but are not limited to, people with developmental disabilities,cognitive impairment, complex medical problems, significantphysical limitations, and the vulnerable elderly.”14 Patientswith BDD should be included within this designation aspatients with cognitive impairment and also within the realm ofvulnerable juvenile and adult patients. Research hasdetermined that dentists who received clinical and didacticeducation related to the treatment of patients with specialneeds during predoctoral dental education felt morecomfortable treating these patients and were therefore morelikely to provide such care. However, the majority of dentists(as reported in a number of earlier studies) did not feel wellprepared for the treatment of such patients within their dentaleducation experiences.14,15


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Body Dysmorphic Disorder and Cosmetic Dentistry

Photo: Getty Images

Waldman et al16 reported that there is no simple or singlesolution to prepare soon-to-be dental professionals with theknowledge and willingness to provide necessary oral healthservices for individuals with intellectual and a host of otherdevelopmental disabilities. However, with the condition ofBDD, dentists being comfortable in treating such patientsisn’t the issue; the issue relates more toward the dentistbeing able to manage these patients. In the case of dentalpatients with BDD, cosmetic dentists are often too eager totreat such patients, and these patients are very willing to buywhat the dentists are selling. The issue is to educate dentists,dental faculty, and dental students with the ability to diagnoseBDD, and appropriately manage such patients, as typicallythese patients present with unreasonable demands andexpectations in regard to changing their appearance throughcosmetic therapy.

ETHICAL ISSUES Cosmetic surgery and cosmetic dentistry offer a means ofdecreasing the individual’s appearance of aging, decreasingan overweight appearance, or changing the dynamic of asmile. The concerns of cosmetic dentistry transcend suchindividual dental disciplines as restorative dentistry,prosthodontics, orthodontics, and oral and maxillofacialsurgery.17-20 The reality of the psychiatric diagnosis of BDDraises ethical issues with regard to consideration forpsychiatric referral versus initial and continued cosmetictreatment.7,9,11,21-23 BDD is an increasingly recognizedsomatoform disorder with potential legal malpracticeimplications. Pa tients with this disorder are preoccupied withan imagined problem in the appearance of one or more bodyparts, which leads to clinically significant stress, impairment,and dysfunction. Cosmetic correction of perceived physicaldeficits is rarely an effective treatment. Therefore, relatedclinical cosmetic therapy may result in patientmismanagement with the potential to result in patientdisability, depression, and suicide.24-27

Patients with BDD tend to de mand overtreatment relatedto the imperfections, which they may perceive to be ruiningtheir lives. Cos metic dentistry serves a misconstrued needof these individuals and allows dentists to enable these BDDpatients in the patients’ attempts to correct their perceivedimperfections. The problem for cosmetic dentists is to

recognize patients’ medi cal/psy chological condition and tounderstand how the condition will impact treatmentperspectives. As BDD patients are typically willingparticipants of cosmetic therapy, dentists will usually besuccessful with case presentations and case acceptance.Selling cosmetic dentistry to this patient population isessentially like selling a sandwich to a starving man (butpossibly one who is allergic to bread). As typical BDDpatients do not tend to be satisfied with anything less thanwhat they perceive as absolute unattainable perfection,which exists only in these patients’ minds, they usuallyperceive the cosmetic dental therapy as a failure. Thus, thesepatients may become “nightmare” patients.2,4,5,7,9,11 A re -cent article by a senior dental student examined the issue ofneeds-based dentistry versus cosmetic dentistry.28 Thearticle28 is from the perspective of a dental student (Asbury)with lofty ideals, who has not yet experienced privatepractice. The article examines the impact of the Americanconsumer mentality on the current practice of dentistry.Because American consu merism heavily influences thesmile, there is a greater appreciation with regard toaesthetics as compared to biological function. From theconsumerism viewpoint, a beautiful smile is equated withsuccess, desirability, and youth. But should biological healthand function be substituted for beauty? And what are theethical boundaries regarding selling patients cosmeticservices which may enhance beauty at the expense ofbiologic function and health? The underlying theme withcosmetic dentistry is the economic success of the dentistsperforming cosmetic dentistry services.

Asbury28 quotes a number of articles which havereported the issue of cosmetic dentistry and overtreatmentissues, and concluded that needs-based dentistry and oralhealth should be the focus of modern dentistry, and dentistsshould avoid the spell of the easy money of Americanconsumerism, cosmetic dentistry, and overtreatment.However, the future Dr. Asbury had not yet entered thecommercial realm of private practice and encountered thereality that dentistry is both a profession and a business.Many of the concepts of cosmetic dentistry and needs-based dentistry are welded at the hip and not easilyseparated. Aesthetic considerations are an extremelyimportant aspect of dentistry. However, with regard to


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dental patients seeking cosmetic care, Asbury’s concerns28

are completely relevant, as the percentage of BDD pa tientsseeking cosmetic care is greater compared to dental patientsnot seeking cosmetic care.7 The ethical standard separatingneeds-based dentistry and cosmetic dental over-treatment isnot a sharp demarcation, but more of a fuzzy interface.There fore, the addition of the medical diagnosis of BDD intothis discussion provides another layer of concerns to furtheropen up a discussion regarding the ethics of performingcosmetic dentistry upon BDD patients.

Both Nash29 and Simonsen30 have reported their concernregarding the tendency of dentists to move away from dentalhealthcare, encompassing the prevention and treatment of oraldisease, and toward the new paradigm of increasedprofitability through cosmetic dentistry. Accord ing to Nash29

and Simonsen,30 the emphasis upon aesthetics andcosmetics appears to be moving dental care more toward aneconomic business model compared to a patient-centeredprevention, diagnosis, and treatment model. The cosmeticeconomic business model ac centuates beauty but has thepossibility of diminishing health and longevity. With regard toselling cosmetic dentistry to patients with BDD, the behavior isanalogous to throwing a drowning man an anchor or pouringgasoline on a fire. In such cases, the dentist is destined to havecase acceptance and economic benefit, but little or nopossibility of a positive outcome for the patient. Therefore,dental education regarding BDD allows an opening to discussethical issues within dentistry. Furthermore, discussion of BDDopens up further dialogue re garding the ethical issues relatedto treatment planning and choice of dental materials utilizedwithin cosmetic dentistry, as certain cosmetic materials areproblematic with regard to longevity when compared to lesscosmetic dental materials.31-35

CONCLUSIONThe current task with regard to BDD is to educate dentists,dental faculty, and dental students concerning the diagnosisand management of BDD and introduce the importance ofBDD as an educational and ethical topic within the literatureand continuing dental education, and within both the didacticand clinical dental education curriculum.

REFERENCES1. Phillips KA, Dufresne RG Jr. Body dysmorphic

disorder: a guide for primary care physicians. PrimCare. 2002;29:99-111, vii.

2. Herren C, Armentrout T, Higgins M. Body dysmorphicdisorder: diagnosis and treatment. Gen Dent.2003;51:164-166.

3. Honigman RJ, Jackson AC, Dowling NA. The PreFACE:A preoperative psychosocial screen for elective facialcosmetic surgery and cosmetic dentistry patients. AnnPlast Surg. 2011;66:16-23.

4. Naini FB, Gill DS. Body dysmorphic disorder: a growingproblem? Prim Dent Care. 2008;15:62-64.

5. Scott SE, Newton JT. Body dysmorphic disorder andaesthetic dentistry. Dent Update. 2011;38:112-118.

6. Leone JE, Sedory EJ, Gray KA. Recognition andtreatment of muscle dysmorphia and related bodyimage disorders. J Athl Train. 2005;40:352-359.

7. De Jongh A, Oosterink FM, van Rood YR, et al.Preoccupation with one’s appearance: a motivatingfactor for cosmetic dental treatment? Br Dent J.2008;204:691-695.

8. Sarwer DB, Crerand CE, Magee L. Body dysmorphicdisorder in patients who seek appearance-enhancingmedical treatments. Oral Maxillofac Surg Clin NorthAm. 2010;22:445-453.

9. De Jongh A, Aartman IH, Parvaneh H, et al.Symptoms of body dysmorphic disorder amongpeople presenting for cosmetic dental treatment: acomparative study of cosmetic dental patients and ageneral population sample. Community Dent OralEpidemiol. 2009;37:350-356.

10. Vulink NC, Rosenberg A, Plooij JM, et al. Bodydysmorphic disorder screening in maxillofacialoutpatients presenting for orthognathic surgery. Int JOral Maxillofac Surg. 2008;37:985-991.

11. Hepburn S, Cunningham S. Body dysmorphic disorderin adult orthodontic patients. Am J Orthod DentofacialOrthop. 2006;130:569-574.

12. Ishigooka J, Iwao M, Suzuki M, et al. Demo graphicfeatures of patients seeking cosmetic surgery.Psychiatry Clin Neurosci. 1998;52:283-287.

13. Commission on Dental Accreditation. Accreditationstandards for dental education programs. Chicago, IL:American Dental Association; 2010.

14. Krause M, Vainio L, Zwetchkenbaum S, et al. Dentaleducation about patients with special needs: a surveyof U.S. and Canadian dental schools. J Dent Educ.2010;74:1179-1189.


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15. Dao LP, Zwetchkenbaum S, Inglehart MR. Generaldentists and special needs patients: does dentaleducation matter? J Dent Educ. 2005;69:1107-1115.

16. Waldman HB, Fenton SJ, Perlman SP, et al. Preparingdental graduates to provide care to individuals withspecial needs. J Dent Educ. 2005;69:249-254.

17. Christensen GJ. Esthetic dentistry—2008. AlphaOmegan. 2008;101:69-70.

18. Christensen GJ, Ruiz JL. Restorative dentistry: currentdevelopments and a look to the future. Dent Today.2008;27:98-102.

19. Nathanson D. Current developments in estheticdentistry. Curr Opin Dent. 1991;1:206-211.

20. Weinstein AR. Esthetic applications of restorativematerials and techniques in the anterior dentition.Dent Clin North Am. 1993;37:391-409.

21. Korner A, Gerull F, Meares R, et al. The nothing that issomething: core dysphoria as the central feature ofborderline personality disorder. Impli cations fortreatment. Am J Psychother. 2008;62:377-394.

22. McFarland MB, Kaminski PL. Men, muscles, andmood: the relationship between self-concept,dysphoria, and body image disturbances. Eat Behav.2009;10:68-70.

23. Yang FM, Jones RN. Measurement differences indepression: chronic health-related andsociodemographic effects in older Americans. Psycho -som Med. 2008;70:993-1004.

24. Hunt TJ, Thienhaus O, Ellwood A. The mirror lies:body dysmorphic disorder. Am Fam Physician.2008;78:217-222.

25. Nachshoni T, Kotler M. Legal and medical aspects ofbody dysmorphic disorder. Med Law. 2007;26:721-735.

26. Pavan C, Simonato P, Marini M, et al.Psychopathologic aspects of body dysmorphicdisorder: a literature review. Aesthetic Plast Surg.2008;32:473-484.

27. Tobin HA. What makes a patient unhappy. Facial PlastSurg Clin North Am. 2008;16:157-163.

28. Asbury A. Putting your money where your mouth is: theinfluence of American consumer culture oncontemporary dentistry. J Am Coll Dent. 2011;78:22-26.

29. Nash DA. Dentistry a larger sense of purpose: dentistryand society. J Am Coll Dent. 2007;74(2):27-33.

30. Simonsen RJ. Overtreatment? You bet it is! J EsthetRestor Dent. 2007;19(5):235-237.

31. Christensen GJ. Dentistry’s forced return to its roots. J Am Dent Assoc. 2011;142(12):1393-1395.

32. Koin PJ, Kilislioglu A, Zhou M, et al. Analysis of thedegradation of a model dental composite. J Dent Res.2008;87(7):661-665.

33. Mackert JR, Wahl MJ. Are there acceptablealternatives to amalgam? J Calif Dent Assoc.2004;32(7):601-610.

34. Wahl MJ, Schmitt MM, Overton DA, et al. Prevalenceof cusp fractures in teeth restored with amalgam andwith resin-based composite. J Amer Dent Assoc.2004;135:1127-1132.

35. Wahl MJ. Amalgam—Resurrection and redemption.Part 1: the clinical and legal mythology of anti-amalgam. Quintessence Int. 2001;32(7),525-535.


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POST EXAMINATION INFORMATION

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POST EXAMINATION QUESTIONS

1. Body dysmorphic disorder (BDD) is also known as:

a. Dysphagia.

b. Dysmorphophobia.

c. Dysmorphogenesis.

d. Dysmorphic syndrome.

2. BDD is relatively common but is under-recognized. Insevere cases individuals with BDD may be unable towork or socialize.

a. The first statement is true, the second is false.

b. The first statement is false, the second is true.

c. Both statements are true.

d. Both statements are false.

3. BDD patients are preoccupied with imagined defectsin appearance. The patients’ concern is excessiveonly if the defect is considered excessive.





4. Up to _____% of BDD patients express specificconcerns regarding dental appearance.

a. 10.

b. 20.

c. 30.

d. 40.

5. Vulink et al reported that _____% of patients seekingcosmetic orthognathic oral and maxillofacial surgerywere diagnosed with BDD.

a. 5.

b. 10.

c. 13.

d. 18.

6. Herren et al reported that BDD patients seekingdental care demonstrated the following behavior(s):

a. Distress over minor dental flaws.

b. Attempting to cover up a flaw.

c. Unjustified dissatisfaction with other dental treatment.

d. All of the above.


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7. BDD patients seeking dental care may haveexcessive requests for unnecessary dentaltreatment.

a. True.

b. False.

8. BDD is an increasingly recognized somatoformdisorder. Cosmetic correction of a BDD patient’sperceived physical deficits is usually an effectivetreatment.





9. BDD patients are typically willing participants ofcosmetic dental treatment. Dentists will usually besuccessful with case presentations and caseacceptance with BDD patients.





10. The percentage of BDD patients seeking cosmeticdental care is greater compared to patients notseeking cosmetic care.

a. True.

b. False.


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Body Dysmorphic Disorder and Cosmetic Dentistry Dysmorphic Disorder and Cosmetic Dentistry Diagnostic, ... such as tooth color, ... Body Dysmorphic Disorder and Cosmetic Dentistry