Helping Patients Overcome Cosmetic Dental Insecurities
Dentists should prioritize screening for body dysmorphic disorder (BDD) before proceeding with cosmetic procedures, as cosmetic interventions typically worsen psychological outcomes in patients with BDD, and instead refer these patients for cognitive behavioral therapy as first-line treatment. 1
Screen for Body Dysmorphic Disorder First
Approximately half of young people with BDD report a desire for cosmetic procedures, and one in 10 undergo cosmetic procedures before age 20, but psychological outcomes are typically poor—most feel disappointed with results, experience deteriorating mental health, or shift their appearance concerns to another feature. 1
Ask patients directly about the degree of distress and functional impairment their dental concerns cause, as BDD is characterized by preoccupation with perceived defects that are not observable or appear slight to others. 1
Assess for repetitive behaviors such as excessive mirror checking, comparing their appearance to others, seeking reassurance about their appearance, or hiding the perceived defect. 1
BDD is considered a particularly high-risk psychiatric disorder with approximately half of affected young people reporting self-harm and high rates of suicidal ideation. 1
When BDD is suspected, refer to mental health services for cognitive behavioral therapy (CBT) with exposure and response prevention, which shows large effect sizes (Cohen's d = 1.22) in reducing BDD symptoms. 1
Use Shared Decision-Making for Appropriate Candidates
Employ a shared decision-making model where clinicians, patients, and caregivers work together to decide on the best care options, rather than simply presenting information. 2
Discuss the merits and drawbacks of all viable treatment options, ensuring patients understand the consequences, limitations, and potential failures of treatment later in life. 3
Obtain informed consent preferably in writing, with clearly documented clinical notes detailing all investigations, findings, and discussions that have taken place. 3
Use multimodal presentation techniques to maximize patient understanding, including visual aids, figures, and plain language. 2
Prioritize Minimally Invasive Approaches
Start with the least invasive procedures such as bleaching alone or combined with direct resin composite bonding, which can satisfy many patients' demands while being kinder to teeth and having much better fall-back positions for future requirements. 4
Avoid aggressive reduction of sound tooth tissue, as elective removal of healthy enamel and dentine can result in pulpal injury, poorer periodontal health in the long term, and structural weakening of teeth. 4
Consider enamel shaping via direct tooth contouring or application of resins to correct defects, asymmetries, and shape or rotation problems before more invasive options. 5
Reserve veneers and crowns for cases where less invasive procedures are insufficient, as these aggressive treatments can produce significant morbidities in previously healthy teeth. 4
Address Psychological Factors Directly
Recognize that psychological elements and female gender are the main predictors of seeking dental therapy, not the actual clinical dental status. 6
Identify patients who hide their teeth during smiling, as this is the most important predictor for choosing fixed prosthetic restorations (OR 9.1) and bleaching (OR 5.8). 6
Be cautious about accepting patients with unrealistic cosmetic expectations, as this group has heightened expectations that may not be achievable. 3
Understand that self-perceived malposition and lower satisfaction levels are significant predictors for seeking treatment, independent of objective clinical findings. 6
Common Pitfalls to Avoid
Never proceed with invasive cosmetic procedures in patients with suspected BDD, as this violates the duty of candour and can result in significant psychological harm. 1, 4
Avoid overtreatment that is unnecessarily destructive and goes against the healing and caring principles of the dental profession. 7
Do not assume that achieving the desired cosmetic outcome will resolve underlying psychological distress in patients with appearance-related anxiety. 1
Recognize that aggressive reduction of sound tooth tissue is not biologically neutral and results in structural weakening, particularly problematic in young patients. 4
When Mental Health Referral is Indicated
Refer immediately when patients demonstrate excessive preoccupation with minor or imagined dental defects that cause significant distress or functional impairment. 1
Consider referral when patients have undergone multiple cosmetic procedures with persistent dissatisfaction or shifting concerns to different features. 1
Recognize that approximately half of young people with BDD accessing specialist mental health services report self-harm, making risk assessment crucial. 1