My experience treating a patient with body dysmorphia
Body dysmorphia is a growing mental health condition and can present itself even in the dental practice. Satnam Sall highlights a recent situation and explains how she dealt with it.
I recently had a young lady visit me for a cosmetic consultation. On first impressions I admired her stylish dress sense and she appeared to look after herself. However, once we started discussing her reasons for coming in, it became clear that something wasn’t quite right.
She told me she hated her teeth and they were a cause of great unhappiness and distress. They were affecting her life so much that she couldn’t leave her house and consequently was unemployed. She wanted a ‘quick solution’ to make her smile better and expressed her wishes to have 10 porcelain veneers placed.
This immediately raised red flags, but I decided to continue the consultation and assess the oral cavity first before saying anything to the patient. She presented with poor oral hygiene, moderate-severe teeth crowding and cavities in two teeth.
I communicated these findings to the patient. Her response was that she had seen another dentist but decided against treatment. The dentist wanted to place silver fillings in her teeth, something she didn’t want. This had become an uncomfortable situation for me and I could see alarm from my nurse. I had already decided I couldn’t treat this patient. She was showing signs of body dysmorphia disorder. But I wasn’t sure if she had any insight into her own body dysmorphia beliefs. I knew I had to tread with caution.
Confronting the problem
It was worrying how to approach the conversation. To the best of my ability I calmly expressed my concerns to the patient. I explained I did not feel she was suitable for cosmetic treatment at this time. Her beliefs and distress indicated she needed psychological support.
I emphasised that she also needed to be dentally fit before entering into cosmetic treatment. Furthermore, I explained that at a later stage we may be able to reassess for cosmetic treatment, but I would not recommend veneers. It is a destructive procedure, unless we align her teeth first.
The patient burst into tears. As she wept, she disclosed further negative thoughts about herself. It was clear that this was an individual with low self-esteem and self-worth. She also confided that she was aware her thoughts were not ‘normal’.
We ended the consultation concluding the patient required psychological support in place before going any further.
During the next 10 minutes we kept a watchful eye on the patient who continued sobbing in the bathroom and eventually came out after some gentle encouragement. Eventually a member of her family came to collect her.
I am pleased to say that we followed up on the patient and she is now receiving the support she needs.
I have to admit it was a very challenging situation. This was my first experience of managing a patient with body dysmorphia. I was disheartened when the patient started crying, but I wonder whether there could have been any other reaction to the difficult nature of the conversation we had. I’m thankful my nurse remained in the room the entire time to support me and pacify the patient.
To help me reflect, I decided to look into body dysmorphia and its relevance to dentistry. I hope this is useful to any young dentists who find themselves in a similar situation.
Body dysmorphia disorder
Body dysmorphia is a common psychiatric condition in which an individual is disproportionately concerned about an aspect of their appearance. The perceived flaw or defect in their appearance may not be observable or appear slight to others. But it will preoccupy the individual and cause significant distress, social or occupational impairment.
If you suspect that an individual is displaying body dysmorphia, ask yourself if the distress is proportionate to the dental concern.
As clinicians we see many patients looking to improve the appearance of their teeth. But if the individual reports their teeth are stopping them from getting a job or leaving the house, you can consider this disproportionate behaviour to the actual dental problem.
As always, you must take a thorough medical history. Sometimes the individual may have already been diagnosed with body dysmorphia.
It is likely that patients are not aware of their body dysmorphia beliefs. But there may be others who do not wish to share that information. In suspecting cases it is a sensitive question the clinician would need to ask.
Medication taken such as anti-depressants are useful clues. Screening tools are also available to help establish whether patients have body dysmorphia beliefs. But it is important to note they are not diagnostic.
Body dysmorphia in dentistry
Dentists are not qualified to make a diagnosis of body dysmorphia, however these tools may be useful for decisions on making referrals.
Individuals with body dysmorphia are very likely to seek cosmetic dental treatment. But the provision of treatment is contra-indicated. Studies show that submitting to patient’s requests for cosmetic treatment does not benefit the patient and does not improve patient’s body dysmorphia symptoms. It could prove detrimental for both the patient and the treating clinician. The patient might present with unattainably high standards or expectations that the dentist is unlikely to satisfy.
Naturally it will feel uncomfortable for dentists to talk about body dysmorphia with patients. It may not provoke a positive reaction. But it is important to remember you need this to act in the patient’s best interests.
If the patient is not receiving any psychological support, then the first step is to make a referral through the patient’s GP. Ideally with the patient’s consent.
Communication is central in helping the patient understand the benefit of accessing support. Be considerate of the patient’s emotions and make a plan to reassess treatment at a later stage once the individual is in a better position with their anxieties and stress.
Ensure you record contemporaneous notes detailing discussions and outcomes.