M E N TA L H E A LT H

COVER STORY

ABSTRACT Mental disorders in dental practice:

Given the high prevalence of mental dis-
orders in Western societies, dentists
may be confronted with behaviors that
may interfere with the safe and efficient
delivery of dental care. This paper
addresses the need for dentists to be
aware of patient vulnerability factors and
psychological problems due, for exam-
ple, to the possible negative effects of
psychological distress and critical inci-
dents, and their consequences for both
symptom presentation and dental treat-
ment planning. This need for awareness
is illustrated by a case report of a
patient who developed body dysmorphic
disorder (BDD)—a preoccupation with
some imagined defect in physical
appearance—following dental treatment.
KEY WORDS: psychiatry, psycholo-
gy, mental disorder, Body Dysmorphic
Disorder
A case report of body
dysmorphic disorder
Ad de Jongh DDS, PhD1*; Pauline Adair, MS2
1
Department of Social Dentistry and Dental Health Education, Academic Centre for Dentistry
Amsterdam, Louwesweg 1, 1066 EA Amsterdam, The Netherlands, and Centre for Special Dental Care,
Amsterdam; 2Department of Clinical Psychology, The Royal Hospitals, Belfast, United Kingdom.
*Corresponding author. E-mail: a.de.jongh@acta.nl
Spec Care Dentist 24(2): xx-xx, 2004
Introduction
Many people show aberrant, inappropriate, or abnormal behavior. Such behavior is
often indicative of a psychological, psychiatric, or mental disorders, which are grouped
under the term “psychopathology.” Psychopathology is said to exist when unpleasant,
painful emotions, experiences, or behavior impair a person’s life to such an extent that
he or she can no longer function properly, to the detriment of his or her own well-
being and that of others.1
Epidemiological research has shown that the occurrence of mental disorders is high
in Western societies. In the National Comorbidity Study carried out in the United
States in the early 1990s, nearly 50% of people suffered at least one lifetime disorder.
This morbidity appears to be more highly concentrated in roughly one sixth of the
population who have a history of three or more comorbid disorders.2 Similarly, the
most frequently seen mental disorders in the United Kingdom—affecting one in six
adults aged 16-74 years—are depression, anxieties or phobias, or a combination of
these.3
Given the high prevalence of mental disorders, dentists may frequently treat
patients who have noticeable deviant or problematic behavior as well as patients who
have psychiatric disorders that are not identified or obvious.4 This paper addresses the
need for dentists to be aware of patient vulnerability factors and psychological prob-
lems due, for example, to the possible negative effects of psychological distress and
critical incidents, and their consequences for both symptom presentation and dental
treatment planning.

Psychopathology and reality (e.g., delusions or hallucinations).

dentistr y
Some mental disorders are easily identi-
fied. For example, one could easily rec-
ognize the presence of a mental disorder
when a patient shows signs of a serious
psychiatric problem, such as severe men-
tal retardation, voluntary assumption of
inappropriate or bizarre postures, or
when the patient clearly loses touch with
However, signs of mental disorders are
not always so obvious. Often, the dental
patient is not inclined to offer unsolicited
information, either because he or she feel
it is not necessary information for the
dentist or because the patient is embar-
rassed. Further, dentists usually do not
ask questions about one’s psychological
health, perhaps with the exception of
dental anxiety. Dentists may avoid this

S p e c C a r e D e n t i s t 2 4 ( 2 ) 2 0 0 4 55
M E N TA L H E A LT H

aspect of a patient’s health history the dental practice. Somatoform disor- ing. The dentist recommended that the
because they feel that they are not ders include somatization disorder, con- patient have an oral surgeon extract her
trained to approach this topic or because version disorder, hypochondriasis, third molars, which were decayed.
they do not see the relevance. somatoform pain disorder, malingering, Although Mrs. K. later reported that she
Clearly, it is not the dentist’s job to factitious disorder, and body dismorphic had considerable doubts about the pro-
assess a patient’s mental state or to disorder.7 The somatoform disorders are posed surgery, she was afraid to express
decide whether or not the patient has a defined as a group of disorders in which them to the dentist.
psychological dysfunction. However, physical symptoms suggest a physical Mrs. K. expected that the oral sur-
when it is recognized that patients’ disorder for which there is no demon- geon would do an assessment and give
symptoms may be of psychological ori- stratable underlying physical basis. her more information on the procedure
gin, dentists have a duty to refer the Moreover, there is a strong presumption so that she could reach an informed deci-
patient to a specialist (e.g., psychologist that the reported physical symptoms are sion about whether to have the teeth
or psychiatrist) for a mental health linked to psychological factors.11,12 extracted. The oral surgeon, however,
assessment and appropriate treatment. Researchers suggest prompt identifica- assumed that the dentist had already
Another major reason why the dentist tion, which will prevent the practitioner informed the patient of the nature of the
should have some knowledge of psy- and patient from becoming caught up in proposed treatment and that the patient
chopathology is that many mental health a pattern of extensive and unnecessary had consented to the procedure. On
conditions interfere with dental treat- diagnostics and pointless or even harm- arrival at the oral surgeon’s office, the
ment. This applies particularly to unco- ful treatment.13,14 patient was given a local anesthetic, and
operative patients, for example, who Because dentistry involves many the surgery was performed with Mrs K
experience phobic anxiety about a partic- tasks that stress technical aspects, den- feeling that she was powerless to stop it.
ular aspect of dental treatment or who tists should make a conscious effort to be All four wisdom teeth were extracted at
may have had a history of sexual abuse.5,6 aware of, and sensitive to, the needs of the same time.
Other examples of problem behaviors psychologically vulnerable patients Mrs K. emotionally breaks down
arising from psychopathology that may before embarking on dental treatment. when she arrived at home. She felt vio-
adversely influence the delivery of dental This is illustrated by the following case lated and was unconvinced that the treat-
care include a disinterest in performing report of a patient who developed a ment was necessary. On looking in the
appropriate preventive self-care and oral somatoform disorder following dental mirror the next morning, she started to
hygiene among patients who are treatment. think that her appearance had complete-
depressed,7 behavioral problems associat- ly changed, that her upper and lower
ed with substance-dependency or cogni- jaws were out of alignment. She per-
tive impairment,8 and dental erosion Case repor t ceived that her upper jaw had moved for-
resulting from certain eating disorders.9 When Mrs K. came for a routine dental ward and her lower jaw had recessed.
The Table lists a number of main cate- visit, she was 32 years old, divorced with Mrs. K. was deeply shocked by what she
gories of mental disorders that are likely three children, and suffering from signifi- perceived as a devastating change in her
to be seen by the dental practitioner.10 cant psychological distress, partly caused facial profile. In subsequent months, she
Patients who suffer from somatoform by ongoing difficulties involving her suffered from frequent headaches and
disorders also can require special care in efforts to combine childcare with study- developed difficulty sleeping. She spent
hours every day thinking about her facial
Table 1. Mental Disorder Categories the Dentist May Encounter. defect. She eventually stopped studying
because she could no longer concentrate.
Disorder Category Examples She also felt that she could not breathe
Depression, dysthymic disorder, bipolar disorder (manic-depressive properly and, in general, was deeply
Mood Disorders
illness) unhappy.
Anxiety Disorders
Panic disorder, generalized anxiety disorder, obsessive-compulsive Two weeks after the third molars had
disorder, social phobia, post-traumatic stress disorder, specific phobia been extracted, Mrs. K. visited the oral
Somatisation disorder, hypochondriasis, conversion disorder, body surgeon and asked him to restore her
Somatoform Disorders
dysmorphic disorder
supposed deformity to its original state
Sleeping Disorders Dyssomnia, parasomnia with implants. The oral surgeon refused
because, in his view, implant placement
Substance-Dependence Alcohol or drug dependence would not change the set of the jaw.
Feeling that nothing could be done to
Eating Disorders Anorexia nervosa, bulimia nervosa
restore her appearance, Mrs. K. became
Personality Disorders Borderline personality disorder, antisocial personality disorder deeply depressed and attempted suicide.
Mrs. K.’s physician referred her to a

56 S p e c C a r e D e n t i s t 2 4 ( 2 ) 2 0 0 4 Body Dysmorphic Disorder: A Case Report


psychiatric outpatient clinic where she
described her problems at initial assess-
ment. She expressed that she would like
a referral for implant placement. Mrs K
perceived that placement of the implants
would resolve her problems. The thera-
pist referred Mrs. K. to a dentist who was
unable to find any damage or imperfec-
tions resulting from the extractions. Mrs.
K. considered implants to be her only
hope for restoring her appearance and
her health and expressed her desperation
and anger to the dentist. The dentist
explained that no dental treatment was
needed and referred Mrs. K. back to the
psychologist. Mrs. K. restated that her
teeth were the problem and said she
would rather consult with another den-
tist. No further outcome on this case is
known.
Discussion
This case report, although extreme, illus-
trates—mainly from the patient’s per-
spective—how a psychological state can
interfere with dental treatment planning.
In Mrs. K.’s case there were several psy-
chosocial factors, in terms of stressful
circumstances at work and home. These
vulnerability factors may have depleted
Mrs K.’s emotional reserves, while at the
same time, it would seem that the nega-
tive dental experience exacted a toll that
greatly exceeded her emotional
resources. This not only led to a number
of serious trauma-related psychological
problems and suicidal behavior, but the
dental treatment also disrupted her per-
ception of her appearance.
A patient who is psychologically vul-
nerable should not be treated in a rapid
manner. In addition, it seems in this case
that neither the dentist or the oral sur-
geon provided Mrs. K. with all of the rel-
evant information about the proposed
treatment. Since dentists and specialists
are obligated to obtain informed consent
and give the patient time to make a truly
informed decision, the question exists
whether such behavior is ethical under
any circumstance, regardless of the
patient’s psychiatric state.15
The symptoms demonstrated by Mrs.
K. after the dental treatment, meet the
Friedlander et al.
criteria for a serious psychiatric disorder.
In this particular case report, the symp-
toms led the psychologist to conclude
that there was a preoccupation with a
imagined defect in physical appearance.
The diagnosis provided in this case was
body dysmorphic disorder (BDD) also
known as dysmorphophobia, literally
meaning “fear of ugliness.”14,17
Although BDD may not be a very
common mental disorder, it is considered
to be one of the underlying causes of
patient dissatisfaction with a certain
physical or dental feature, such as the
appearance of the teeth, facial asymme-
try, or disproportion of the shape, size, or
some other aspect of the mouth, lips,
Mrs. K. considered
implants to be her
only hope for restoring
her appearance and
her health and expressed
her desperation and
anger to the dentist.
chin. or jaw.15 It is known that BDD caus-
es significant distress and impairment in
functioning and that people with BDD
often pursue and receive dental and sur-
gical treatments to rectify their imagined
defects. It is believed that such treat-
ments may cause the disorder to worsen,
leading to intensified or new preoccupa-
tions.14 Therefore in Mrs. K.’s case, the
question as to whether implant place-
ment was indicated could only be
answered after thorough examination
and questioning, and should have been
considered in light of Mrs. K.’s psy-
chopathological condition. This case his-
tory not only underscores the importance
of teaching dentists about psychological
functioning but also that dentists need to
be aware of the role played by psychoso-
cial factors in the development and per-
sistence of dental problems and symp-
toms.
Rather than providing Mrs. K. with
dental implants, the preferred treat-
M E N TA L H E A LT H
ment—at least initially—would be to
encourage Mrs. K. to undergo psy-
chotherapy. Psychotherapy could help
her to deal with her experiences with the
dentist and oral surgeon and her per-
ceived victimization. However, successful
referral for therapy will only be possible
if the patient recognizes the need for psy-
chiatric or psychotherapeutic involve-
ment, which is not always the case. The
authors’ experiences suggest that patients
with such types of conditions could be
more receptive to a psychotherapy refer-
ral when the emotional pain that the
problem is causing is discussed. Mrs. K.’s
perception of a devastating change in her
appearance, and the anger and sense of
powerlessness this had caused, made it
even more difficult for her to cope with
the existing stresses in her life. Help
from a psychologist could minimize the
effects of the problems that arose after
her dental treatment.
Cognitive and behavioral treatment
strategies have received the most atten-
tion and empirical support in treating
BDD.16 Regarding pharmacotherapy, sero-
tonin reuptake inhibitors seem to be
effective in reducing BDD symptoms.17
Because BDD can be a difficult condition
to treat, it is particularly important to
keep the patient calm and acknowledge
that the patient is suffering. The dentist
should realize that a form of follow-up
care is required for such patients, partic-
ularly if he or she decides that no treat-
ment is needed; otherwise, the patient
may continue to pursue treatment from
other dentists, delaying the necessary
psychological care.14
Conclusion
A direct relationship is seldom found
between some form of mental illness and
the problem that has led the patient to
consult the dentist. Likewise, a dental
patient’s behavior does not often express
the presence of psychological difficulties
or psychopathology to the extent that it
adversely impinges on dental treatment.
On the other hand, untreated mental
health problems can cause the patient
much suffering. In addition, many psy-
chological problems will take a more
S p e c C a r e D e n t i s t 2 4 ( 2 ) 2 0 0 4 57
M E N TA L H E A LT H
favorable course if identified and treated
early. Since effective psychotherapy or
psychopharmacology can considerably
alleviate the suffering caused by moder-
ate to deep depression or anxiety disor-
ders, it is valuable for all health profes-
sionals, including dentists, to have some
skill in identifying the signs of psy-
chopathology. By listening carefully and
observing signs of unbalanced behavior
the dentist may get the feeling, or come
to the conclusion, that a patient may be
suffering from psychological problems
rather than a dental problem.
The case of Mrs. K. highlights the
need for dentists to
• be aware of patients’ difficulties and
psychological functioning (just as they
are aware of systematic conditions such
as diabetes and hypertension);
• develop the ability to recognize the
importance of psychological health in a
patient’s overall presentation; and
• refer a patient who is having psycho-
logical difficulties for appropriate men-
tal health care.
By developing a greater comfort level
in considering psychological concerns
among patients, dentists may not only
prevent unnecessary or complicated
58 S p e c C a r e D e n t i s t 2 4 ( 2 ) 2 0 0 4
als with caring for patients with dementia.
treatments, but also may reduce frustra-
Special Care Dentist 20:147-54, 2000.
tion experienced by both patient and
9. Woodmansey KF. Recognition of bulimia ner-
dentist.
vosa in dental patients: implications for den-
tal care providers. Gen Dent 48:48-52, 2000.
References 10. American Psychiatric Association. Diagnostic
and statistical manual of mental disorders.
1. Double D. The limits of psychiatry. Br Med J
4th ed. Washington, DC: APA; 1994.
324:900-4, 2002
11. Barsky AJ. A comprehensive approach to the
2. Kessler RC, McGonagle KA, Zhao S, et al.
chronically somatizing patient. J Psychosom
Lifetime and 12-month prevalence of DSM-
Res 45:301-6, 1998.
III-R psychiatric disorders in the United
12. De Jongh A. Clinical characteristics of soma-
States. Results from the national comorbidity
tization in dental practice. Br Dent J
survey. Arch Gen Psychiatry 51:8-19, 1994.
195:151-4, 2003
3. Office for National Statistics. Psychiatric mor-
13. Portegijs PJ, van der Horst FG, Proot IM,
bidity among adults. London: Office of
Kraan HF, Gunther NC, Knottnerus JA.
National Statistics, 2000.
Somatization in frequent attenders of gener-
4. Hughes AM, Hunter S, Still D, Lamey PJ.
al practice. Soc Psychiatry Psychiatr
Psychiatric disorders in a dental clinic. Br
Epidemiol 31:29-37, 1996.
Dent J 166:16-9, 1989.
14. Coulthard P, Morris S, Hamilton AJ.
5. De Jongh A, Bongaarts G, Vermeule I, Visser
Unexplained physical symptoms in dental
K, De Vos P, Makkes P. Blood-injury-injec-
patients. Br Dent J 184:378-82, 1998.
tion phobia and dental phobia. Behav Res
15. Bailey BB. Informed consent in dentistry. J
Ther 36:971-82, 1998.
Am Dent Assoc 110:709-13, 1985.
6. Willumsen T. Dental fear in sexually abused
16. Cororve MB, Gleaves DH. Body dysmorphic
women. Eur J Oral Sci 109:291-6, 2001.
disorder: a review of conceptualizations,
7. Friedlander AH, West LJ. Dental management
assessment, and treatment strategies. Clin
of the patient with major depression. Oral
Psychol Rev 21:949-70, 2001.
Surg Oral Med Oral Pathol 71:573-8, 1991.
17. Phillips KA. Body dysmorphic disorder: clini-
8. Chalmers JM. Behavior management and com-
cal aspects and treatment strategies. Bull
munication strategies for dental profession-
Menniger Clin 62:A33-48, 1998.
Body Dysmorphic Disorder: A Case Report