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Review Article

Chasing Perfection: Body Dysmorphic Disorder and its

Significance in Dentistry
Shruti S. Kumar1, Vishal Shrishail Kudagi2, Gurvinder Kaur3
Departments of Pedodontics and Preventive Dentistry and 2Orthodontics, JSS Dental College and Hospital, JSS University,
1

Mysore, Karnataka, 3Consultant Pediatric Dentist, Fortis Memorial Research Institute, Gurgaon, Haryana, India

Abstract
Body dysmorphic disorder (BDD) is a type of mental illness, a somatoform disorder, wherein the affected person is concerned with body image,
manifested as excessive concern about, and preoccupation with a perceived defect of their physical features. The individual may perceive a
defect in either one feature or several features of their body, which causes psychological distress that impairs occupational or social functioning.
Considerable numbers of these patients are obsessed with the appearance of their dentition and the shape of their jaws. Usually, the dentist
can be the first to diagnose this condition which may otherwise pass unnoticed. This problem can sometimes interfere to a large extent in
rendering appropriate dental treatment. BDD has remained an elusive topic for both researchers and clinicians likewise. This condition needs
further research which can greatly help in intercepting and preventing its myriad lethal manifestations.

Keywords: Body dysmorphic disorder, eating disorders, physical appearance, selective serotonin reuptake inhibitors

Introduction of functioning resulting from the appearance preoccupation;

Man’s obsession with physical appearance can be dated back
to thousands of years. However, today, this preoccupation has
risen to new heights, thanks to popular media, which has been
playing a very important role in molding one’s psyche. Every
second of every day, people are being bombarded with images
of impossibly flawless models with immaculate facial features
and physique, which influences a person with average physical
traits in a negative way. This ever‑increasing frenzy about
beauty has given rise to a myriad number of psychological
disorders such as “body dysmorphic syndrome,” “anorexia
nervosa,” and “bulimia nervosa.”
Body dysmorphic disorder (BDD) is defined by Diagnostic
and Statistical Manual of Mental Disorders (DSM)‑1V‑TR
as a condition marked by excessive occupation with an
imaginary or minor defect in a facial feature or localized
part of the body.[1] The diagnostic criteria mentioned for this
condition in the DSM, Fourth Edition, Text Revision are
as follows: (1) a preoccupation with an imagined or slight
defect in appearance (if a slight physical defect is present,
the person’s degree of concern is extreme); (2) marked
distress or impairment in social, occupational, or other areas
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and (3) the preoccupation is not attributable to the presence
of another psychiatric disorder (e.g., anorexia nervosa).[1] This
condition was archaically known as dysmorphophobia or body
dysmorphia.[2]
BDD is recognizable by damage to self‑esteem, fear toward
social situations, depression, suicidal tendencies, and an
obsession to seek nonpsychiatric medical or surgical treatment
to improve imagined flaw in their appearance.[3] Although
BDD is a psychiatric disorder, most patients visit cosmetic
surgeons seeking to meliorate their perceived defect.[4]
Unfortunately, such remedies prove futile to the patient and
the practitioner.[4]
Given the increasing prevalence of psychiatric disorders,
dentists may be confronted with behaviors that may interfere
with the safe and efficient delivery of dental care. Although
a few case descriptions of BDD have been reported in dental
Address for correspondence: Dr. Shruti S. Kumar,
Department of Pedodontics and Preventive Dentistry, JSS Dental
College and Hospital, SS Nagar, Bannimantap, Mysore, Karnataka, India.
E‑mail: shrutiskmr@yahoo.co.in
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non-commercially, as long as appropriate credit
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For reprints contact: reprints@medknow.com

DOI: How to cite this article: Kumar SS, Kudagi VS, Kaur G. Chasing perfection:
10.4103/jioh.jioh_22_17 Body dysmorphic disorder and its significance in dentistry. J Int Oral Health
2018;10:157-60.

© 2018 Journal of International Oral Health | Published by Wolters Kluwer - Medknow 157
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Kumar, et al.: Dental arch morphology in asthmatics
practices,[5,6] the prevalence rate of BDD patients, who seek
esthetically motivated dental treatment, is still unclear.
Most people who present themselves for cosmetic treatment
are likely to have underlying psychological conditions that
need to be addressed. BDD, a disorder characterized by
extreme appearance preoccupation, may be of particular
relevance to orthodontists and other dental specialists who
offer cosmetic procedures. This review focuses on some key
issues pertaining to BDD and its implications in dentistry. The
article also emphasizes on the need for further research in the
field. Knowledge and awareness about this condition can aid
the dentist to recognize and alleviate the problem at the earliest.
History
BDD was first documented in 1886 by an Italian
psychopathologist named Enrique Morselli as
“Dysmorphophobia.” Dysmorphophobia comes from a Greek
word “dysmorfia,” meaning ugliness, especially of the face,
which first appeared in the “Histories of Heroditus.” It refers to
a myth of the “ugliest girl in Sparta,” who on being touched by a
goddess transforms into a beautiful woman. This condition was
not published in the DSMs until 1987. There was a consensus
to call the disorder BDD and not “Dysmorphophobia” as it was
perceived that the term implied to the presence of a behavioral
pattern of public avoidance. In the fourth edition of the DSM,
it was eventually renamed BDD.[7]
There is an interesting situation documented by the
psychologist Sigmund Freud about a patient in his practice who
was so preoccupied with the appearance of his nose that it was
hardly possible for him to go through his routine life due to
the obsession. The patient’s name was Sergei Pankejeff, who
was also referred to by the nickname “the Wolf Man.” It would
seem Sergei Pankejeff had all the classic symptoms of BDD.[7]
Prevalence
BDD has been studied for more than a century. However,
the exact prevalence rate of it in the general demographics is
not well defined. Studies of the prevalence of this disorder in
psychiatric patients and the general population suggest that
BDD is relatively common, affecting up to 2% of the general
population,[8] and up to 12% of the psychiatric patients.[9]
A recent study reported a 7.5% incidence in an orthodontic
patient sample compared with a 2.9% incidence in a general
public sample.[10] This study suggested that a higher percentage
of the general population affected with BDD could be
seeking orthodontic treatment. Furthermore, there is a higher
prevalence of BDD in women.[11]
Onset and Course
The onset of symptoms generally occurs in adolescence or
early adulthood, where most personal criticism of one’s own
appearance usually begins.[12] This condition might worsen
with age. Often, if a person struggles with image concerns
158 Journal of International Oral Health  ¦  Volume 10  ¦  Issue 4  ¦  July-August 2018
at a young age, they become more unhappy as they struggle
with the physical changes that come with age (gray hair, loss
of hair, wrinkles, and weight gain). BDD is considered to
be continuous rather than intermittent.[13] Signs and severity
change consistently. Cure in totality relating to symptoms
appears to be uncommon, even after the treatment.[14]
Etiology
The factors that play a vital role in the development of this
disorder are categorized under neurobiological, psychological,
and sociocultural.
Neurobiologic factors
Impaired serotonin and dopamine activity have an effect in the
etiology of BDD, as demonstrated by the fact that individuals
positively respond to medications that alter levels of these
neurotransmitters.[8] Many studies imply that BDD may be
triggered by conditions involving inflammatory pathways that
can interfere in the process of serotonin synthesis.[15] Neural
injury to the frontotemporal region of the brain could also result
in BDD symptoms as reported by a case study.[16]
Psychologic factors
Justifications from the psychoanalysis point of view suggest
deep‑rooted conflicts in subconscious relating to sexuality and
emotions, the projection of feelings of guilt, and inferiority to
certain body parts.[17] There have also been justifications that
this disorder develops from a complex interaction of cognitive,
emotional, and behavioral factors.[18] Cognitive elements that
appear to be monumental in the development and persistence of
BDD include irrational attitudes about body image pertaining
to perfection and symmetry, obsessive self‑analyzing for the
presence of physical flaws, and relating the facial expressions
of others as being critical to one’s appearance.[19] From a
behavioral perspective, BDD is thought to emerge from the
positive reinforcement of appearance characteristics and social
learning.[20]
Sociocultural factors
Individual raised in a household that is rejecting, neglectful,
abusive, or critical as related to issues of esthetics and
outwardly appearances, may be associated with BDD.
Another important factor for an individual to suffer from this
condition is excessive bullying in school and play areas. The
ever‑increasing obsession on physical perfection in the media
is yet another force in the etiology of both general body image
dissatisfaction and the appearance preoccupations among
persons with BDD.
Dental Implications of Body Dysmorphic
Disorder
Neziroglu et al. found that 86% of their BDD sample mentioned
some aspect of their face.[21] Common preoccupations include
different physical aspects of the head, nose, teeth, ears, lips,
mouth, and jaws. Therefore, dentists especially orthodontists
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Kumar, et al.: Dental arch morphology in asthmatics
and maxillofacial surgeons come across such patients often
in their practice. Such patients are extremely concerned about
minute dental defects, such as minimal crowding or proclination
of anterior teeth, dental rotations, interdental spacing, and
other imperfections. The patient’s chief complaint needs to
be thoroughly evaluated for any exaggerated perceptions of
the defect and the actual need for the dental treatment should
be analyzed. The key is to take a detailed history and ensure
complete awareness of the patient’s expectations and whether
they are within the realms of reality. Patients suspected of
having BDD should be referred to a psychiatrist for definitive
diagnosis and management.
Treatment
The treatment of BDD consists of pharmacotherapy and
behavioral therapy. Sometimes, performing the esthetic
procedure requested might be an integral part of the
patient’s treatment; however, this should always be based
on the recommendation of the treating psychiatrist. The
primary treatment modalities for BDD include the use of
selective serotonin reuptake inhibitors (SSRIs). Evidence
for SSRIs in the treatment of BDD supports the use of
SSRIs such as “fluoxetine,” fluvoxamine, escitalopram,
and citalopram.[22] Cognitive behavioral therapy is another
common treatment approach. Cognitive behavioral therapy
pertains to diagnosing and modification of appearance‑related
cognitions and behaviors. Methods used in this approach
are self‑monitoring of thoughts and behaviors related to
appearance (e.g., analyzing of time spent mirror gazing);
cognitive techniques (e.g., challenging distorted thoughts about
one’s appearance); and behavioral exercises (e.g., exposing
the patient to a feared situation and preventing involvement
in obsessive behaviors).[23] Various studies justify the use of
cognitive behavioral therapy an effective treatment modality
for BDD.[24]
According to Neziroglu et al., BDD is common in some
psychiatric and cosmetic settings but is poorly identified.[25]
In another study, BDD was identified mainly in those with
depression, substance abuse, or an anxiety disorder. The
authors emphasize on diagnosis if missed could lead to an
inappropriate treatment which might cause exacerbation of the
existing condition. Yet, its prevalence and correlates are poorly
understood in younger age groups.[26‑28] Many authors have also
correlated BDD with the occurrence of obsessive–compulsive
disorder.[29‑33] Furthermore, eating disorders have to be ruled
out before diagnosing BDD.[34]
Although there have been various studies, there is still need
for future research which should include measurements of
clinical severity in surveys of BDD. Measurement tools need
to be updated with changing times.[35,36]
Conclusion
Much more research is needed on all aspects of BDD. Advances
in knowledge will likely lead to the future refinements of this
Journal of International Oral Health  ¦  Volume 10 ¦ Issue 4 ¦ July-August 2018
disorder’s diagnostic criteria and an increased understanding
of the BDD’s relationship to other medical and psychiatric
disorders. The stress of BDD can be very severe. The stress can
lead to an unending search of unnecessary medical and surgical
procedures, avoiding daily activities, avoiding job duties,
avoiding social situations, and suicidal thoughts and attempts.
The additional research is required to investigate further BDD
among patients who present for various dental treatments.
Awareness among the dentists about various dimensions and
magnitude of this disorder can help in the identification of the
condition and prevent the devastating consequences, it can
have on the individual’s mental and physical well‑being.[37‑40]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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