Dr Mike Rutherford, Senior Dentolegal Consultant at Dental Protection, looks at why dental practitioners should be alert to the risks of treating patients with body dysmorphic disorder.

Body dysmorphic disorder is something that is poorly understood but it is important for dental practitioners to have some awareness, in order to effectively identify and manage patients who are affected by the condition.

What is body dysmorphic disorder?

It is a recognised psychological disorder that was first described in the Diagnostic and Statistical Manual of Mental Disorders, which is produced by the American Psychiatric Association. The disorder is characterised by a preoccupation with physical and aesthetic defects or imagined defects – often the face, skin and hair. It is equally proportioned in genders, usually begins in late adolescence and often presents in the early 30s. It is generally continuous through life to a lesser or greater extent and rarely has spontaneous remission. It is characterised by:

1. A preoccupation with appearance:

• Men – often it is the genitals, height, hair and body build
• Women – weight, hips, legs and breasts
• Usually five to seven body parts over the course of the disorder

2. Obsessive thoughts lasting hours every day

3. Compulsive behaviours – skin picking, mirror checking, disguising or camouflaging the area of concern

What impact does it have on the people who suffer from it?

Body dysmorphic disorder leads to distress and impairment of functioning. Many people also have obsessive compulsive disorders and alcohol abuse is a common finding. Body dysmorphic disorder can render some sufferers housebound, and lead to suicidal ideation for many at some or several points of their life. Unfortunately, many members of society – including dental practitioners – think this is a silly pickiness that can be sorted out by a bit of rational explanation: it can’t.

Looking at the frequency, many patients are not diagnosed, but a population frequency of 1-3% is accepted, so for the average dental practitioner this will likely mean one patient every week or two. It also means that quite a few practitioners reading this article will statistically be part of this cohort – as a profession we are not exempt.

What does this mean for cosmetic dentistry?

The frequency in differing practices is also skewed: cosmetic or dermatological medicine is demonstrated to attract a disproportionate number of patients with body dysmorphic disorder. It would therefore seem predictable that dental practices that promote themselves as cosmetic will attract more body dysmorphic patients. Advertising of these cosmetic services will naturally attract these patients.

Dentistry has undergone an extraordinary change in direction over the last 30 years. We have moved from being about purely treatment and prevention of disease to also being a provider of cosmetic and aesthetic treatments – with some practices doing this exclusively: the ubiquitous orthodontic treatment, teeth bleaching, Botox and fillers; and cosmetic tooth treatments such as veneering. This has been brought about by affluence, revolutionary products and techniques, and a consumer driven market who know about these treatments, can do their ‘research’ online and know what they want.

It is estimated that the majority of body dysmorphic patients seek cosmetic treatments – liposuction, rhinoplasty, Botox, tooth whitening; and frighteningly many are provided with the requested treatment. This is an alarming statistic because almost all patients with body dysmorphic disorder who undertake treatment report they are disappointed with the outcome. This is simply because they have a psychological disorder and not a physical disorder. Treating the perceived defect will not cure the disorder.

This simple statement and statistic should drive our approach to offering cosmetic procedures to patients we suspect may have unrealistic or unattainable expectations from treatment.

How dental practitioners can avoid risk

We as a profession are not particularly adept at diagnosing or picking patients with body dysmorphic disorder, but we can follow a few basic ground rules that will help us avoid trouble down the road. These ground rules begin on day one. Most patients with body dysmorphic disorder doctor-shop; a patient who presents with a history of disappointment with previous dentists and treatments (not just dental) may just be unlucky but perhaps there is more to the story – be aware. Patients who ‘talk you up’, telling you how great you must be, or what a great job you did on their friend…take a reality check – most of us are not that great that we deserve praise before we provide treatment.

Warning sign number two: patients who may seem to know as much or more about the treatment than you do – this may be part of the obsession. They have researched this treatment extensively and this can lead to a multitude of problems.

Firstly, the research and the perfect results your patient has seen online may differ from what you intend or what you can do. Their facial shape, facial symmetry or features may dictate that the whole result will not be like the examples on your website. Beware the temptation to agree to a particular treatment, product or process that your patient demands because that is what they want. Stick instead to what you know and what works best in your hands.

Secondly, this patient research can lead to failures in the consent process; our patient knows so much that we may not enforce the consent process as much as we normally would – the risks and warnings, the advice on likely outcomes –because our patient seems to know all about it already. Conversely our patients may not listen when a practitioner describes risks and warnings, limitations and likely outcomes – why should they? They have researched this thoroughly and know how it should turn out. They may tune out of this discussion because they have already envisioned the outcome and just want to get on with it. This is not a patient problem – it is our problem because it is our professional obligation to ensure the consent process is valid.

Thirdly – and this is the red flag we should not miss – when the defect or deficiency that your patient describes is so minor that in your opinion you can barely detect it, or you don’t believe that it is an actual defect. If you can’t see it, you can’t fix it. You have to be able to say no.

Making sure that your consent process is sound and providing your patients plenty of information, visuals of the outcome, mock-ups, time in temporary veneers or crowns is all very helpful, but sometimes you just need to say no. Patients can be persuasive, they may flatter us, they may tell us how much they trust us, they may try coercion – but if you can’t envision how the result is going to look significantly different, you have to say no.

It doesn’t matter how good your consent process is, no-one wants to deal with a disappointed and angry patient who believes that you have ruined their teeth, or at best, wasted their time and money.

For a more in-depth discussion with Dr Rutherford on this topic, listen to the podcast “The role of body dysmorphia” – available now. Our Casematters episode “I look like a horse” takes a deeper dive into real case study to consider the learnings behind them.