Evaluating the Knowledge and Practices of Dental Practitioners in Screening Body Dysmorphic Disorder Patients in Aesthetic Dentistry: A Cross-Sectional Survey

Evaluating the Knowledge and Practices of Dental Practitioners in Screening Body Dysmorphic Disorder Patients in Aesthetic Dentistry: A Cross-Sectional Survey | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Evaluating the Knowledge and Practices of Dental Practitioners in Screening Body Dysmorphic Disorder Patients in Aesthetic Dentistry: A Cross-Sectional Survey Puja Sabherwal, Michael Chan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7007371/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Body dysmorphic disorder (BDD) is a psycho-pathological condition which is on the rise particularly among young adults. These patients frequently visit the dental clinics for aesthetic, cosmetic and orthodontic interventions and pose a challenge to the unaware dental practitioner. Therefore, we conducted a study to assess the knowledge and practice among dentists based in India, United Kingdom and Australia on screening/managing patients with body dysmorphic disorder. Further the study aimed to compare these trends of existing knowledge based on clinical experience, speciality, gender and location and provide a review of literature to better understand this area. Materials and methods A survey was undertaken amongst clinicians to assess current knowledge among dentists on BDD screening/practices. An online questionnaire was issued to approximately 300 dental practitioners via dental association groups, research recruitment university portals and social media groups/portals across India, United Kingdom and Australia. Ninety-two participant responses were received and analysed. Results A significant majority of the participating dentists recorded basic (32.3%) to moderate (34.4%) awareness about BDD screening. Overall, a substantial proportion (45.6%) of the dentists who received the survey globally reported lack of any defined written or verbal questionnaire in their practice to screen for BDD. Similarly, more than half the dentists surveyed did not study BDD psychology or its management in the university curriculum nor in continuing education courses. It was noteworthy that 40% of the participating dentists had no defined protocol on how to provide a psychologic referral for suspected or known patients of BDD. More experienced clinical practitioners and those specialising in aesthetic, restorative, or orthodontics had heightened awareness and management for BDD. Training for BDD was reported by dentists in UK and Australia to be more advanced when compared to India. Conclusions The authors recommend a universal management strategy when encountering any patients with psychological problems like BDD. The results advocate the use of screening both verbal and written questionnaire based is suggested during patient interview prior to treatment. Education and awareness are essential for enhancing dentist-patient outcomes in cases involving BDD, and for ensuring appropriate management. Health sciences/Diseases Figures Figure 1 Introduction Body Dysmorphic Disorder (BDD) is described (as per American Psychiatry Association) as increased pre-occupation with a perceived or mild physical defect in the body. In general, individuals have a human desire to be perceived as attractive or good-looking. 1 However, when this desire becomes pathological affecting the psychological, social or vocational functioning of any individual, it must be addressed. The desire is considered pathological when it is excessive, obsessive, runs in repetitive patterns and has a negative impact on social, vocational or mental health of the individual. 2 In the era of increased use of social media, peer pressure and work pressure, BDD is on the rise particularly among young adults. Correspondingly, the prevalence of BDD patients in medical and dental settings is also on the rise. These patients often demand for aggressive interventions and irreversible, radical procedures which may be unnecessary. Consequently, there is a high rate of dissatisfaction from the procedures carried out. They may also have had a history of changing multiple practitioners in the past. 3 Evidence indicates that screening for body dysmorphic disorder prior to aesthetic procedures may enhance patient satisfaction, protect the patient, and safeguard practitioners from performing inappropriate treatment. 4 A recent write-up 5 suggests useful screening practices for dentists regarding BDD and modifications to aesthetic dental treatment. Numerous authors have published similar findings and recommendations 6,7,8,9 No study was found which performs a clinical survey to assess the existing knowledge and practice among dentists on screening BDD patients. Furthermore, no systematic review or meta-analysis are available in this area. More structured research and studies will provide data required to fabricate an evidence-based set of guidelines on screening and managing BDD patients. As aesthetic dentists, these will be beneficial in the management of the aesthetically driven patient and potential identification of BDD prior to commencement of treatment. Aim & Objectives To assess the knowledge and practice among dentists based in India, United Kingdom and Australia on screening patients with body dysmorphic disorder. Primary objective To assess the existing knowledge of dentists across India, Australia and United Kingdom on screening BDD patients in their respective dental practice. To understand present practice and understanding on dealing with BDD patients in respective clinical practice among above-mentioned cohort of dentists Secondary objective To compare difference in knowledge and practice on dealing with BDD patients among different dentists based on age, experience, region of practice and degree/field of specialisation or formal training received To conduct a narrative literature review of the same Background Body dysmorphic disorder-definition and understanding The diagnostic and statistical manual on mental disorders (DSM-5) by the American Psychiatric Association describes body dysmorphic disorder (BDD) as an exaggerated preoccupation with a perceived bodily defect or severe concern wherein there is a mild/slight bodily defect often associated with excessive distress and functional impairments. The innate individual’s desire to look good and perceived to be attractive is a natural human trait. However, when this desire becomes pronounced, obsessive and exaggerated to the point of affecting one’s quality of life and functioning, it is referred to as dysmorphophobia/BDD. 1,2 The International Classification of diseases (ICD-11) published by the World Health Organization's defines BDD as continuous persistent preoccupation with bodily defect(s) which may or may not be noticeable to other individuals. Individuals are convinced that they are being noticed/judged for these slight body defects. 10 Clinical criteria The affected individuals may spend greater than 3 hours per day obsessing over one or more body part over a minor/imaginary deficit. The body parts usually include skin, hair, nose but may change and involve 5–7 body parts over the course of the individual’s lifetime. The preoccupation with physical appearance may vary between 3–8 hours per day and is often associated with guilt, shame, anger and disgust. These feelings are not pleasurable and emotionally distressing for the patient. 11 BDD is often found to be associated with obsessive compulsive disorder and would include a clinical pattern of repetitive habits such as checking in mirror, skin picking, comparing appearance to others, seeking reassurance from others, grooming and so on. 12 BDD tends to impact the academic, social and occupational functioning of the affected individual making them inclined to become home-bound and adversely affect their quality of life. Patients may avoid intimate relationships and may even have a suicidal predilection. 13 As per the DSM the following diagnostic criteria are employed to diagnose BDD 14 - Preoccupation with an imaginary body deficit. If at all the deficit exists, it is mild and the person’s concern is excessive proportional to the degree of deficit. The above-mentioned preoccupation causes significant impact on functioning of the individual in social, vocational, occupational and other roles of life. This cannot be attributed to another mental health disorder (such as anorexia, etc). Psychopathology and Aetiology of body dysmorphic disorder Social, psychological, cultural and biological factors may play a role in the development of BDD. An impairment in the brain circuits frontal-striatal, temporo-parietal-occipital have been suggested which leads to hampered processing of facial images and emotions. The serotonin system may also play a role since the depletion of tryptophan has been associated with exacerbations in the symptoms of BDD. 14,15 A cognitive-behavioural model for BDD has also been proposed wherein the patient has an unrealistic ideal goal for appearance, excessive focus on self and negative perception of the body image. There may be some degree of overlap between BDD and other social disorders such as health anxiety, obsessive-compulsive disorder and social phobia. The individual enter a viscous cycle, they perceive themselves as aesthetic objects and negatively appraise the same leading to emotions of disgust, shame, rumination, depression and safety behaviour to camouflage the appearance to look ‘better’. 16 Demographic strata and prevalence of BDD The global prevalence of BDD is estimated to be 2.2% among students, 1.9% among adolescent population and 3.3% among adult psychiatry settings. It was reported to be 13.2% in cosmetic surgery settings, 5.2% in orthodontics and cosmetic dentistry setting and 11.2% in orthognathic surgery. Overall, the prevalence was found to be higher in females compared to males. 17 Practice-based prevalence studies in dentistry In the dental setting, a study was conducted by Hepburn and Cunningham, 2006, in United Kingdom to assess the prevalence of BDD among 40 patients using the Yale Brown Obsessive Compulsive Disorder Questionnaire for Body dysmorphic BDD-YBOCS scale and found prevalence of 7.5% (males-6.3%, females-8.3%). 18 Another study by De Jongh et al, 2009 in Netherlands reported an overall prevalence of 4.1% among dental patients in aesthetic dentistry set-up. 19 A study in Iran [Yassei et al , 2014] reported a prevalence of 5.2%. 20 The above-mentioned studies have been conducted among patients seeking orthodontics/aesthetic dental procedures. These findings suggest that approximately every 5–7 in 100 patients would be diagnosed with body dysmorphic disorder in aesthetic/orthodontic areas of dental practice. This leads us to reflect as aesthetic dentists that the prevalence is significant and should be screened for prior to initiating treatment planning in the interest of best practice for the patient and clinician. BDD and its impact in medical settings BDD will be discussed in the general medical settings first so its behavioural manifestations, screening protocols and treatment modifications may be extrapolated and better understood in the field of aesthetic dentistry. Dermatology In the field of dermatology, BDD patients may be frequent visitors who are perpetually dissatisfied with the treatment received. The patient’s level of physical disfigurement does not correlate proportionally with grade of patient’s concern for the same. One third of the patients visiting the dermatology settings have a psychiatric illness. BDD is also a common condition which needs to be screened for and treated using a joint dermatological-psychiatric approach. 21 Cosmetic surgeries BDD patients often resort to unnecessary dermatological intervention or cosmetic surgeries. 22 Overall, the patient demand for cosmetic procedures is on the global rise. In the year 2015, a total of 21.9 million patients sought surgical/non-surgical cosmetic intervention globally. 23,24 Therefore, the prevalence of BDD patients in these settings are also increasing. Some authors truly believe that patients of BDD have no positive outcome or benefit from undergoing cosmetic surgeries. 23,25 The practice of cosmetic surgeries on BDD patients without correction of underlying psychiatric impairment may lead to lawsuits/threats or even physical assaults from patients. 26 Some patients have severe BDD where the condition impacts social, day-to-day life with associated avoidant behaviour, anxiety, depression, self-mutilation (even do-it-yourself surgeries). Studies mentioned above suggest that these patients should not be taken up as candidates for cosmetic surgeries. Other studies suggest that mild-moderate BDD patients with no impact on day-to-day functioning may be taken up for surgery with carefully nuanced decision-making as this gives the patients a newer perspective. 27 Psychiatric settings BDD patients may undergo severe mental turmoil, distress and poor social and occupational life. They may suffer from higher suicidal ideations and a mean of 2.6% were found to attempt suicide per year. 28 It is essential to diagnose the underlying BDD since it may be masked by the associated co-morbid conditions. Psychiatric interviews and screening questionnaires serve as useful aids. Depending on the grade and severity, the psychiatrist prescribes cognitive psychotherapy, pharmacotherapy or a combination of the two. Overall, this is a lifelong illness, relapses-remissions are common. 29 General Medical Settings The prevalence varies between 5–13% depending on the setting, population and diagnostic criteria employed. Overall, these patients report to general primary care medicine with chief complaints pertaining to appearance. Even a brief interview may reveal their anxiousness, obsessiveness with physical defect which may not correlate to the size or magnitude of the same. The same should be screened, assessed and referred for suitable care ahead with note to referring physician. A summary for the impact/trends of BDD across medical settings is tabulated. [Table 1 ] Table 1 BDD and its trends in various medical settings Medical Setting Prevalence BDD implications Management recommendation Dermatology 4.9–36% 30 Cosmetic dermatology, defects of skin on exposed areas e.g. face, like acne, scars, pigmentation, facial hair reduction, younger and female patients were found to be more predisposed. Skin picking may be a prominent feature 21 Screening, dermatological intervention where physician feels suitable, psychiatry treatment (adjunct)s Plastic/ cosmetic surgery 6–15% 31 Breasts, buttocks, thighs, toes, facial hair surgeries, lip enhancement which may be of average/normal size others like fat reduction with higher women predilection 32 Relative or complete contraindication to cosmetic surgery as management without correcting underlying psychiatric problem would lead to threat/lawsuit or even assault Psychiatry settings (in-patient/out-patient 3.5–15% 33 Impairment of social/occupational life, distress, suicidal ideation, comorbid with obsessive-compulsive disorder, eating disorder, social anxiety, unipolar depression, The underlying BDD tends to be masked by co-morbid condition, therefore careful diagnosis required, cognitive behavioural therapy, pharmacotherapy like selective serotonin reuptake inhibitors, tricyclic antidepressants, anxiolytics, serotonin-noradrenaline reuptake inhibitors. General medical settings 5–13%, variable Report to primary healthcare settings with chief complaint regarding appearance, proportion of concern is much higher compared to volume of physical defect Usually, these patients are referred to dermatology/cosmetic surgery settings, ideally medical practitioners should be aware and screen/assess/refer suitably BDD and its impact in dental settings 3,20 Obsessive Concern/care for dental appearance The patients may become persistently obsessed with any minor flaws in the gums, teeth or smile. This pattern may become so obsessive that it tends to have a detrimental impact on their day-to-day functioning and lives. Avoidant treatment patterns In some cases, the fear of shame/guilt/self-conscious judgement may be so great that the patient avoids visits to the dentist/dental care altogether. Need for aggressive dental treatment These patients may request electively for dental treatment which may be irreversible and unnecessary. The procedures may even be radical and aggressive despite having healthy teeth and a physiologically healthy smile. Therefore, previously aggressive dental care may have already been delivered to such patients. A recent study [Kashan et al, 2021] demonstrated that among patients in oral surgery group opting for facial cosmetic surgery was highly predisposed (16.7%) to BDD. 34 Poor treatment outcomes Patients with BDD may be constantly dissatisfied with the treatments received. They may have unrealistic expectations and look for perfectionism even away from reality perspective. Relevance of BDD for field of aesthetic dentistry BDD patients often request for dental whitening and orthodontic treatment procedures. 35 Another study demonstrated that over one third of the dental visits among BDD patients was for crowns and restorative work. 20 The patients tend to be visiting specialities of prosthodontics, orthodontics and aesthetic dentistry on a higher side as per a study in 2008. 19 BDD is also found to have a direct correlation with the dissatisfaction related to dental procedures. Those who were found to have increased sensitivity to flaws were found to be more dissatisfied with dental treatments. 3 Screening questionnaires for BDD The diagnosis of BDD is a nuanced one, the diagnosing physician/dentist needs to be attentive to basic cues. A verbal interview, questionnaires or a combination may be a thorough practice to screen for BDD patients among busy outpatient settings. A compilation of some useful screening tools is made in Table 2. 4 The diagnosis of BDD includes a more detailed assessment. The diagnosis may be done by means of BDDE (Clinician examination) questionnaire. In the dental settings, it must be employed prior to elective orthognathic surgeries. Another diagnostic tool is BDD (self-report) examination. Further a Structured Clinical Interview for BDD (SCID) is published which is time-consuming and usually utilised in psychiatric settings only. However, despite the presence of these tools in literature, there is no global consensus on mandatory screening for BDD by the average general dentist. The awareness and application may vary for each dental practitioner. Present literature and lacunae Despite rising pattern, prevalence and behaviours following body dysmorphic disorder in both medical and dental settings, there are no standardised guidelines for screening BDD patients in general or specialist dental practice. The knowledge and practice of dentists may be variable for the same globally depending on social, cultural and economic factors and type of dental practice. A study was performed among oral surgeons to assess their knowledge, attitude and practice on managing psychological issues among surgery patients. The study demonstrated low knowledge among 40% surgeons in United Kingdom wherein majority has no inter-disciplinary practice to refer patients to psychology care. 36 There is evidence to suggest that screening for BDD should be carried out in interest of patient satisfaction and doctor’s security prior to general aesthetic clinical procedures. 4 A recent publication [Rosten & Newton, 2020] 5 suggests useful screening practices for dentists regarding BDD and modifications to aesthetic dental treatment. Few literature reviews regarding the same are also available. 6–9 However, no study was found which performs a clinical survey to assess the existing knowledge and practice among dentists on screening BDD patients. Further, no systematic review or meta-analysis are available in this area. As aesthetic dentists, having a systemic set of guidelines on screening, management and guidance on care for BDD patients which is practical to inculcate in routine OPD settings would be useful. Further, for those dentists or areas which have poor existing knowledge on BDD or its screening, integration in dental curriculum and continuing dental education programs in this regard would be helpful. Aim of present research Therefore, as stated above, the present study aimed to validate and administer a questionnaire to dentists to assess their knowledge and practice on screening patients with body dysmorphic disorder visiting their dental practice. Further, to compare difference in knowledge and practice on dealing with BDD patients among different dentists based on age, experience, region of practice and degree/field of specialisation or formal training received. Based on data available, the study reviewed the current understanding among dentists on screening and management of BDD in the field of aesthetic dentistry. Methods Ethical Clearance The study protocol was approved from the research ethics office, King’s College London under minimal risk registry. [MRSU-23/24-40858; 5/1/24] Questionnaire fabrication A questionnaire was fabricated by the research team to assess the screening practices among dentists for body dysmorphic disorder. After informed consent was given, the survey collected data including: demographic details such as age, gender, area/country of practice, years of clinical experience and nature/field of dental practice. The survey included a 7-part questionnaire with graded Likert scales to assess the present awareness, screening practices (written/verbal), inclusion in university curriculum, continuing professional development (CPD) programs, referral protocols, litigation and practice-action on managing BDD patients. [Appendix 1-Study Questionnaire attached] Participant Selection Inclusion criteria Dental practitioners with valid registration to practice with the relevant authorities in the location of: India, Australia and United Kingdom General dentists, general dentists with specialist registration and those enrolled in a formal certificate/diploma/degree program practicing in India, Australia and United Kingdom Exclusion criteria Dentists not actively practising clinical dentistry Recruitment of Study Participants The questionnaire was made using Google forms and Google workspace and circulated digitally. The dental practitioners in the countries: India, United Kingdom and Australia were sent the soft copy of questionnaire (hyperlink format). The dental practitioners in these regions were reached out thereby employing convenience sampling technique. The surveys were distributed to colleagues through professional social media groups, known dentist colleagues, faculty and alumni in India, United Kingdom and Australia. A total of approximately 300 dentists were sent the questionnaire. After attrition, 92 responses were received wherein 98.9% participants consented to fill the questionnaire. Data Storage All responses were saved in confidentiality with no sharing of data to any third party/person. Data Entry and Statistical Analysis The responses once obtained were entered and coded in Microsoft Excel 2019 (Excel 16.0) (2018) for ease of statistical analysis. The data responses were analysed using the SPSS software v23.0. The level of significance was kept at 5%. The demographics and details about BDD awareness, training and practice were presented using frequency and percentage. A comparison of the same between male and female dentists was made using the Mann-Whitney U test. The comparison of trends based of clinician experience, specialisation and area of practice was performed using the Kruskal Wallis test followed by Bonferroni test for multiple comparisons. The correlation of awareness towards BDD with practice and training was assessed with the Spearman rank correlation test. Since the responses to each question were ordinal in nature, non-parametric tests were applied for comparisons. Keyword search strategy Due to non-homogeneity of available literature and lack of systematic reviews and randomised control trials in the area of body dysmorphic disorder in aesthetic dentistry, a narrative review of literature was performed. The available databases PubMed, Medline, Web of Science, Google scholar, OVID and APA PsycINFO were searched using keywords: body dysmorphic disorder, body dysmorph*, dymorphophob*, aesthetic dentistry, dentistry, dental, dental clinic, dent*, medical, awareness, screening, management, knowledge, practice separated by suitable Boolean operators AND, OR and NOT as appropriate in various permutations. The available literature was analysed to form a set of compiled information bank to study knowledge on screening and management on BDD in the field of dentistry in different regions of the world. Study Results Demographic details of participants Table 2 Demographic details of study participants Variable Category N % Age -- Mean: 35.27 SD: 12.64 Gender Female 52 57.8 Male 38 42.2 Experience 5 years or less 40 44.4 6 to 10 years 23 25.6 greater than 10 years 27 30 Area of work Category 1 24 26.7 Category 2 24 26.7 Category 3 22 24.4 Category 4 20 22.2 Country of practice Australia 18 20 India 56 62.2 UK 15 16.7 USA 1 1.1 Category 1: General dental practitioner who has completed formal certificate/diploma or degree in the field of in the field of aesthetic/restorative/ orthodontics or prosthodontics; Category 2: General dental practitioner who is pursuing/ completed formal certificate/diploma or degree in the field of oral medicine/paediatric dentistry/periodontics or maxillofacial surgery; Category 3: General dentist currently pursuing formal certificate/diploma or degree in the field of aesthetic/restorative/ orthodontics or prosthodontics; Category 4: General dentist without any formal specialist training working in government / private sector Table 2 describes the demographic details of the study participants. The participating dentists have a mean age of 35.27 ± 12.64 years with 57.8% females and 42.2% males. The responses obtained from different regions included 62.2% participants from India, 20% from Australia, 16.7% from United Kingdom and 1% from United States respectively. The participants were further divided into categories based on area of experience/training and based on years into clinical practice. Trends on BDD screening /practice among dentists Table 3 Trends on knowledge, screening and practice of BDD patients in dental practice Question Option n % How would you best grade your awareness towards Body Dysmorphic Disorder (BDD) and its implications in the field of aesthetic dentistry? Limited Awareness (1) 17 18.9 Basic Awareness (2) 29 32.2 Moderate Awareness (3) 31 34.4 High Awareness (4) 13 14.4 Does your practice have a set of screening questionnaires (like BDD questionnaire or similar others) employed prior to providing aesthetic dental work to patients? Not Implemented (1) 41 45.6 Partially Implemented (2) 32 35.6 Moderately Implemented (3) 8 8.9 Fully Implemented (4) 9 10 Did your dental university curriculum include any training on assessment of BDD or other psychological conditions among patients? No Inclusion: not covered (1) 45 50 Limited Inclusion (2) 28 31.1 Moderate Inclusion (3) 10 11.1 Comprehensive Inclusion (4) 7 7.8 Have you attended any continuing professional development course on BDD assessment for dental procedures? No Attendance (1) 51 56.7 Limited Attendance (2) 17 18.9 Moderate Attendance (3) 12 13.3 Comprehensive Attendance (4) 10 11.1 Is there any fixed protocol on how to provide a practice referral to the psychologist from the dental practice if required? No Protocol (1) 36 40 Informal Protocol (2) 29 32.2 Basic Protocol (3) 16 17.8 Established Protocol (4) 9 10 Have you/any colleagues you know faced any litigation from an aesthetic dental work done for the patient? No Incidents (1) 45 50 Rare Incidents (2) 32 35.6 Moderate Incidents (3) 8 8.9 Frequent Incidents (4) 5 5.6 If a suspected/known case of BDD comes to your dental practice demanding for aesthetic work, what would the line of action be at present? No Established Action (1) 19 21.1 Limited Awareness and Action (2) 31 34.4 Basic Action (3) 22 24.4 Comprehensive Action (4) 18 20 Table 3 summarizes trends in Body Dysmorphic Disorder (BDD) awareness, training, and screening among dental practitioners. A large proportion of participants had limited (18.9%) or basic (32.2%) awareness of BDD, while only 14.4% reported high awareness. More than half of the respondents (50%) reported that BDD training was not included in their dental school curriculum, and 56.7% had never attended a professional development course on BDD. Notably, 45.6% of practitioners had no screening protocols for BDD, and 40% had no structured referral system to psychologists. Comparison of BDD Awareness and Practice by Gender, Experience, Specialization, and Location Table 4 Comparison of BDD Awareness and Practice by Gender, Experience, Specialization, and Location Question Male Female ≤ 5yrs 6-10yrs > 10yrs Cat 1 Cat 2 Cat 3 Cat 4 Australia India UK USA p-value Awareness of BDD 2 (2–3) 3 (2–3) 2 (1.25-3) 2 (2–3) 3 (2–3) 3 (2–3)a 3 (1.25-3)a,b 2 (2–3)a,b 2 (1–2)b 3 (2–3) 2 (1.25-3) 2 (2–4) 4 (4–4) 0.016* University Training 2 (1–2) 1 (1–2) 1.5 (1–2)a 1 (1–2)a 2 (1–3) 2 (1-2.75)a 1 (1–3)a,b 1 (1–2)a,b 1.5 (1–2)b 2 (1–3) 1 (1–2)a 2 (1–2)a,b 4 (4–4)b 0.037* Action for Suspected BDD 2 (2-3.25) 2.5 (2–3) 2 (1–3)a 2 (2–3)a,b 3 (2–4)b 3 (2–4)a 3 (1.25-4)a,b 2 (2–3)a,b 2 (1–2)b 2 (2–4) 2 (1–3) 2 (2–3) 4 (4–4) 0.012* Mann Whitney test (male, female), Kruskal Wallis test(experience, category, location); Adjustments for multiple comparisons: Bonferroni test; * indicates a significant difference at p ≤ 0.05; Different superscript letters (a,b) in a row indicates a significant difference between respective pair of groups; Category 1: General dental practitioner who has completed formal certificate/diploma or degree in the field of in the field of aesthetic/restorative/ orthodontics or prosthodontics; Category 2: General dental practitioner who is pursuing/ completed formal certificate/diploma or degree in the field of oral medicine/paediatric dentistry/periodontics or maxillofacial surgery; Category 3: General dentist currently pursuing formal certificate/diploma or degree in the field of aesthetic/restorative/ orthodontics or prosthodontics; Category 4: General dentist without any formal specialist training working in government / private sector Table 4 presents a consolidated comparison of BDD awareness and practice across gender, years of experience, specialization, and location. Awareness and practice varied significantly based on specialization, with practitioners trained in aesthetic/restorative/orthodontics reporting greater awareness than general practitioners without formal specialist training ( p = 0.016 ). Additionally, more experienced practitioners (> 10 years) demonstrated higher levels of structured action for suspected BDD cases compared to those with ≤ 5 years of experience ( p = 0.012 ). University training on BDD also differed significantly by location, with Australian and UK practitioners reporting higher inclusion compared to Indian practitioners ( p = 0.037 ). However, no significant difference between male and female dentists was noted. Table 5 Correlation of knowledge/awareness towards BDD with practice and training Correlation r-value p-value Awareness vs Practice 0.475 < 0.001* Awareness vs Training on Assessment of BDD 0.547 < 0.001* Awareness vs Attending a course on BDD 0.446 < 0.001* Spearman rank correlation test; * indicates a significant correlation at p ≤ 0.05 This table (Table 5 ) presents the correlation of knowledge/awareness towards BDD with practice and training. There was a moderate positive correlation of awareness with practice and training of BDD. Discussion This multinational survey conducted across India, the United Kingdom, and Australia revealed that most participating dentists exhibited only basic (32.3%) to moderate (34.4%) awareness regarding screening for Body Dysmorphic Disorder (BDD). Alarmingly, 45.6% lacked any structured protocol—written or verbal—for BDD screening within their practices. Additionally, over half of respondents indicated that BDD psychology and management were not included in their undergraduate curriculum, nor had they received any continuing education in this area. Furthermore, 40% reported having no defined referral protocol for patients suspected of having BDD. While nearly half had encountered medico-legal challenges, approximately one-third still operated without structured BDD protocols. This highlights a significant gap in professional readiness to manage psychologically vulnerable patients in aesthetic dental practice. Limited practice-based studies have examined the prevalence of BDD in dental populations. A study in prosthodontic clinics found a 7% BDD prevalence with a female predilection, using the Dysmorphic Concern Questionnaire. 37 Alharbi et al . (2023) reported a 34.1% prevalence in East Saudi Arabia using a culturally adapted screening tool. 3 Dutch data (de Jongh et al ., 2008) suggested higher BDD prevalence in cosmetic dental clinics compared to general practice. 19 Hepburn and Cunningham (2006) noted BDD was more common in orthodontic patients (7.5%) than the general population (2.86%) in London, with persistent dissatisfaction reported even after seemingly successful treatments. 18 The current study found no significant differences between male and female dentists in their approach to BDD screening or management. While specific literature on gender-based BDD screening trends among clinicians is lacking, extrapolated data suggest females dental students may demonstrate heightened aesthetic perception, particularly in academic settings. 38,39 Dentists with over a decade of clinical experience reported more structured approaches to BDD management compared to those with fewer than five years in practice in the present study. While direct literature on experience-specific BDD handling is absent, studies on clinical judgment support the idea that experience enhances diagnostic acumen and strategic flexibility. 40,41 Awareness and preparedness for BDD were higher among specialists in aesthetic dentistry, prosthodontics, and orthodontics compared to general practitioners. These clinicians demonstrated clearer management protocols, likely due to both advanced training and frequent patient exposure. Although literature on this correlation is sparse, observational reports suggest BDD is more commonly encountered in cosmetically oriented dental settings. 5,42 The present study identified significant university curricular differences across regions. UK and Australian dental programs incorporated more comprehensive BDD-related content than Indian institutions. While screening practices showed minimal location-based variation, the disparity in educational infrastructure—India having the highest number of dental schools globally—may affect the depth of psychosocial training, including BDD recognition and management. A moderate positive correlation was identified between a dentist’s level of BDD awareness and their quality of practice and training. This underlines the importance of educational exposure in shaping clinical confidence and preparedness for managing such patients. A simple verbal screening prior to aesthetic, orthodontic, or restorative procedures is recommended for all dental patients. Domains to be explored include appearance concerns, behavioural avoidance, social functioning, preoccupation, and psychological distress. It is also noted by the authors that patients with a history of general medical cosmetic surgery, cosmetic dermatology may be more likely to have undiagnosed BDD and appropriate screening is recommended. Experienced clinicians may identify warning signals during patient interactions, reducing the need for formal questionnaires. This pre-screening is vital to safeguard both the patient’s mental health and the clinician’s legal and ethical responsibilities. 17,43 Standardised self-report screening tools like the Body Dysmorphic Disorder Questionnaire, Dysmorphia Concern Questionnaire and Cosmetic Procedure Screening Questionnaire are effective in identifying Body Dysmorphic Disorder (BDD), especially in dental and orthodontic settings where the condition is often under-recognised. These instruments assess core symptoms, distress levels, and severity, with proposed protocols—such as the one by Polo et al. (2011)—aiding clinicians in early detection. 44 Effective BDD management in dental clinics requires identification and early detection through systematic screening and detailed patient interviews. Key areas include the patient's primary complaint, emotional burden, external pressures, prior treatment history, and expectations. Screening for depressive symptoms, anxiety, and suicidal ideation is essential. Positive disclosures regarding self-harm warrant immediate psychiatric referral. Without awareness of BDD contraindications, dentists risk providing inappropriate care and facing legal consequences. A structured, informed approach supports both patient well-being and clinical safety. 6,26 There is ongoing debate about whether patients with Body Dysmorphic Disorder (BDD) should undergo cosmetic dental treatment. Most literature advises against any operative intervention due to high dissatisfaction rates and poor outcomes. Crerand et al. (2005) reported that 91% of BDD patients showed no improvement following aesthetic treatments. 45 These patients are prone to persistently seeking care from multiple providers, increasing the risk of complaints and medico-legal repercussions. Thus, referral to mental health professionals is widely advocated before considering any treatment. However, select cases of mild-to-moderate BDD with realistic expectations may benefit from carefully planned interventions. 27 Referral to psychologists or psychiatrists facilitates evidence-based care through cognitive behavioural therapy (CBT) and pharmacotherapy, particularly SSRIs. CBT aims to desensitise anxiety-provoking thoughts and restructure negative body image beliefs. 46 Only psychologically stabilised patients should be considered for any functional dental procedure. Legally, BDD may impair decision-making capacity, invalidating consent in some cases. The UK’s General Dental Council (GDC) permits non-surgical aesthetic treatments like botulinum toxin for trained dentists but warns of increased litigation risk in BDD cases. Screening and careful patient selection are therefore essential. 26, 47 A summary of key considerations is depicted in Fig. 1 . Conclusion Body Dysmorphic Disorder (BDD) affects an estimated 5–7% of dental patients, particularly in cosmetic, orthodontic, and aesthetic practices. In this cross-national study across India, the UK, and Australia, 51.1% of dentists reported only basic or limited awareness of BDD, and 45.6% lacked any formal screening method—verbal or written—in their practice. Notably, 50% had no exposure to BDD within their undergraduate curriculum, and 56.7% had never attended continuing education related to BDD. Despite nearly half having encountered medico-legal issues, 40% had no defined protocol for psychological referral. Clinicians with greater experience or formal training in aesthetic disciplines demonstrated superior ability to identify and manage suspected BDD cases. No gender-based differences were found, though dentists from the UK and Australia reported stronger university training in BDD management compared to India. Routine verbal and questionnaire-based screening is recommended, especially for aesthetic procedures. Given the unique psychological needs of BDD patients, it is recommended that these issues be addressed before embarking on permanent and irreversible dental treatment. The authors recommend clinicians to have a protocol for the screening of potential BDD patients and a referral pathway for interdisciplinary assessment and treatment. The study advocates for the inclusion of BDD-related content in dental curricula and targeted continuing education programs. Declarations Acknowledgments We would like to acknowledge statistical support from Dr. (Prof) Mahesh Khairnar. Conflicts of Interest There are no conflicts of interest. Ethics Approval The study protocol was approved from the research ethics office, King’s College London under minimal risk registry. [MRSU-23/24-40858; 5/1/24] Funding Statements The authors received no financial support for the research, authorship, and/or publication of this article. Author Contribution Dr. Puja Sabherwal: Conceptualization, Methodology, writing, analysis, original draft, review and editing, data collection Dr. Michael Chan: Data Curation, Formal Analysis, Writing – Original Draft, revision, review and editing, Supervision All authors read and approved the final manuscript. References American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: Text Revision. 4th ed. Washington, DC: American Psychiatric Association; 2000. Singh AR, Veale D. Understanding and treating body dysmorphic disorder. Indian J Psychiatry. 2019;61(Suppl 1):S131–S135. Alharbi A, Alkhathami A, Farooqi FA, Al-Khalifa KS, Shahin S, Nassar E, et al. The prevalence of body dysmorphic disorder and its associated risk factors among dental patients: Why are my patients not satisfied? Cureus. 2023;15(11):e49739. Pereira IN, Chattopadhyay R, Fitzpatrick S, et al. Evidence-based review: Screening body dysmorphic disorder in aesthetic clinical settings. J Cosmet Dermatol. 2023;22:1951–1966. Rosten A, Newton T. Body dysmorphic disorder: A guide to identification and management for the general dental practitioner. Dent Update. 2020;47(4):303–313. Scott SE, Newton JT. Body dysmorphic disorder and aesthetic dentistry. Dent Update. 2011;38(2):112–118. Ahluwalia R, Bhatia NK, Kumar PS, et al. Body dysmorphic disorder: Diagnosis, clinical aspects and treatment strategies. Indian J Dent Res. 2017;28(2):193–197. Kumar SS, Kudagi VS, Kaur G. Chasing perfection: Body dysmorphic disorder and its significance in dentistry. J Int Oral Health. 2018;10:157–160. James M, Clarke P, Darcey R. Body dysmorphic disorder and facial aesthetic treatments in dental practice. Br Dent J. 2019;227(10):929–933. World Health Organization. ICD-11 International Classification of Diseases for Mortality and Morbidity Statistics. 11th Rev. Geneva: WHO; 2018. Pope CG, Pope HG, Menard W, et al. Clinical features of muscle dysmorphia among males with body dysmorphic disorder. Body Image. 2005;2:395–400. Phillips KA, Kaye WH. The relationship of body dysmorphic disorder and eating disorders to obsessive-compulsive disorder. CNS Spectr. 2007;12:347–358. Angelakis I, Gooding PA, Panagioti M. Suicidality in body dysmorphic disorder (BDD): A systematic review with meta-analysis. Clin Psychol Rev. 2016;49:55–66. Pavan C, Simonato P, Marini M, et al. Psychopathologic aspects of body dysmorphic disorder: A literature review. Aesthet Plast Surg. 2008;32(3):473–484. Grant JE, Phillips KA. Recognizing and treating body dysmorphic disorder. Ann Clin Psychiatry. 2005;17:205–210. Veale D. Advances in a cognitive behavioural model of body dysmorphic disorder. Body Image. 2004;1:113–125. Veale D, Gledhill LJ, Christodoulou P, et al. Body dysmorphic disorder in different settings: A systematic review and estimated weighted prevalence. Body Image. 2016;18:168–186. Hepburn S, Cunningham S. Body dysmorphic disorder in adult orthodontic patients. Am J Orthod Dentofacial Orthop. 2006;130(5):569–572. De Jongh A, Oosterink FM, van Rood YR, et al. Preoccupation with one's appearance: a motivating factor for cosmetic dental treatment? Br Dent J. 2008;204:691–695. Yassaei S, Goldani Moghadam M, Aghili H, et al. Body dysmorphic disorder in Iranian orthodontic patients. Acta Med Iran. 2014;52:454–457. Herbst I, Jemec GBE. Body dysmorphic disorder in dermatology: a systematic review. Psychiatr Q. 2020;91:1003–1010. Anderson RC. Body dysmorphic disorder: recognition and treatment. Plast Surg Nurs. 2003;23:125–128. Lee K, Guy A, Dale J, et al. Adolescent desire for cosmetic surgery: associations with bullying and psychological functioning. Plast Reconstr Surg. 2017;139:1109–1118. Valikhani A, Goodarzi MA. Contingencies of self-worth and psychological distress in Iranian patients seeking cosmetic surgery: integrative self-knowledge as mediator. Aesthet Plast Surg. 2017;41:955–963. Bouman TK, Mulkens S, van der Lei B. Cosmetic professionals' awareness of body dysmorphic disorder. Plast Reconstr Surg. 2017;139:336–342. Sweis IE, Spitz J, Barry D, et al. A review of body dysmorphic disorder in aesthetic surgery patients and the legal implications. Aesthet Plast Surg. 2017;41(4):949–954. de Brito MJ, Nahas FX, Cordas TA, et al. Body dysmorphic disorder in patients seeking abdominoplasty, rhinoplasty, and rhytidectomy. Plast Reconstr Surg. 2016;137:462–471. Phillips KA, Menard W. Suicidality in body dysmorphic disorder: a prospective study. Am J Psychiatry. 2006;163:1280–1282. Phillips KA, Menard W, Quinn E, et al. A 4-year prospective observational follow-up study of course and predictors of course in body dysmorphic disorder. Psychol Med. 2013;43(5):1109–1117. Brohede S, Wyon Y, Wingren G, et al. Body dysmorphic disorder in female Swedish dermatology patients. Int J Dermatol. 2017;56(12):1387–1394. Sarwer DB, Spitzer JC. Body image dysmorphic disorder in persons who undergo aesthetic medical treatments. Aesthet Surg J. 2012;32:999–1009. Phillips KA, McElroy SL, Keck PE, et al. A comparison of delusional and nondelusional body dysmorphic disorder in 100 cases. Psychopharmacol Bull. 1994;30:179–186. McGrath LV, Oey L, McDonald S, et al. Patient satisfaction surveys in dental school clinics: a review and comparison. J Dent Educ. 2015;79:388–393. Kashan DL, Horan MP, Wenzinger E, et al. Identification of body dysmorphic disorder in patients seeking corrective procedures from oral and maxillofacial surgeons. J Craniofac Surg. 2021;32(3):970–973. Alhammadi MS, Halboub E, Al-Mashraqi AA, et al. Perception of facial, dental, and smile esthetics by dental students. J Esthet Restor Dent. 2018;30(5):415–426. Pitak-Arnnop P, Hervé C, Coffin JC, et al. Psychological care for maxillofacial trauma patients: a preliminary survey of oral and maxillofacial surgeons. J Cranio Maxillofac Surg. 2011;39(7):515–518. Pérez Rodríguez C, Judge RB, Castle D, Phillipou A. Body dysmorphia in dentistry and prosthodontics: a practice-based study. J Dent. 2019;81:33–38. Althagafi N. Esthetic smile perception among dental students at different educational levels. Clin Cosmet Investig Dent. 2021;13:163–172. Abu Alhaija ESJ, Al-Shamsi NO, Al-Khateeb S. Perceptions of Jordanian laypersons and dental professionals to altered smile aesthetics. Eur J Orthod. 2011;33(4):450–456. Dunphy BC, Cantwell R, Bourke S, et al. Cognitive elements in clinical decision-making: toward a cognitive model for medical education and understanding clinical reasoning. Adv Health Sci Educ Theory Pract. 2010;15:229–250. Elstein AS. Thinking about diagnostic thinking: a 30-year perspective. Adv Health Sci Educ Theory Pract. 2009;14:7–18. Eliyas S, Chana P, Briggs P. Complex dentistry in general practice—What would you do? Prim Dent J. 2019;8(3):64–74. Perugi G, Akiskal HS, Giannotti D, et al. Gender-related differences in body dysmorphic disorder (dysmorphophobia). J Nerv Ment Dis. 1997;185(9):578–582. Polo M. Body dysmorphic disorder: a screening guide for orthodontists. Am J Orthod Dentofacial Orthop. 2011;139(2):170–173. Crerand CE, Phillips KA, Menard W, et al. Nonpsychiatric medical treatment of body dysmorphic disorder. Psychosomatics. 2005;46:549–555. Ipser JC, Sander C, Stein DJ. Pharmacotherapy and psychotherapy for body dysmorphic disorder. Cochrane Database Syst Rev. 2009;(1):CD005332. Lewis K. Dento-legal aspects of non-surgical facial aesthetic procedures. Fac Dent J. 2014;5:68–73 Appendex 1 Appendix 1 is not available with this version. Additional Declarations There is no duality of interest Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7007371","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research","associatedPublications":[],"authors":[{"id":479761027,"identity":"fdc9e05d-85a3-40bc-a215-84ba567dc637","order_by":0,"name":"Puja Sabherwal","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFElEQVRIiWNgGAWjYHCCBDBhAGYX2Mjxg7kFRGsxSDOWbEBw8euDajmcuOEAmIFbqblEwsMPDH/s8szZe59J/ADaYnx+deKHBwYM8vxiB7BqsZyRkCzB2JZcbNlz3Eyyx8BGzuzG280SQEsNZ85OwKrF4EZCggRjA3PihhtpbDd4gLaY3Ti7AaQlweA2Ti3JPxj+1CduuP+M7eYfoF82zzi7+QcBLWkSDGxAX99gY7vNA/I+f+82vLZY9jxIs0hsO15scCaN/bcM0GESN3i3WSQYSOD0izl7TvKND3+q8wyOH2M2fFMBjMr+s5tv/qiwkeeXxuEwBp4EBlQpCTBXAqtyiBb2A2hC/OgCo2AUjIJRMNIBAFoOZP4o7dFcAAAAAElFTkSuQmCC","orcid":"","institution":"King's College London","correspondingAuthor":true,"prefix":"","firstName":"Puja","middleName":"","lastName":"Sabherwal","suffix":""},{"id":479761028,"identity":"5c21ce7d-0147-48ca-b4b1-f482812e9c2a","order_by":1,"name":"Michael Chan","email":"","orcid":"https://orcid.org/0000-0003-4237-6818","institution":"King's College, London","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Chan","suffix":""}],"badges":[],"createdAt":"2025-06-30 07:17:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7007371/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7007371/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86214834,"identity":"9ca0d723-6f9f-4170-bc87-5ed25e754aa5","added_by":"auto","created_at":"2025-07-08 05:52:56","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":469504,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7007371/v1/8a5de0f89bc24ae8b9d29238.jpg"},{"id":101202483,"identity":"7c45aa63-a952-4444-b799-022bfdf14595","added_by":"auto","created_at":"2026-01-27 09:34:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2124555,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7007371/v1/fab0eb96-d293-4fbd-9517-7ba620b5ae17.pdf"}],"financialInterests":"There is no duality of interest","formattedTitle":"Evaluating the Knowledge and Practices of Dental Practitioners in Screening Body Dysmorphic Disorder Patients in Aesthetic Dentistry: A Cross-Sectional Survey","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBody Dysmorphic Disorder (BDD) is described (as per American Psychiatry Association) as increased pre-occupation with a perceived or mild physical defect in the body. In general, individuals have a human desire to be perceived as attractive or good-looking.\u003csup\u003e1\u003c/sup\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eHowever, when this desire becomes\u0026nbsp;pathological affecting the\u0026nbsp;psychological, social or vocational functioning of any individual, it must be addressed. The desire is considered pathological when it is excessive, obsessive, runs in repetitive patterns and has a negative impact on social, vocational or mental health of the individual.\u003csup\u003e2\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;In the era of increased use of social media, peer pressure and work pressure, BDD is on the rise particularly among young adults. Correspondingly, the prevalence of BDD patients in medical and dental settings is also on the rise. These patients often demand for aggressive interventions and irreversible, radical procedures which may be unnecessary. Consequently, there is a high rate of dissatisfaction from the procedures carried out. They may also have had a history of changing multiple practitioners in the past.\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Evidence indicates that screening for body dysmorphic disorder prior to aesthetic procedures may enhance patient satisfaction, protect the patient, and safeguard practitioners from performing inappropriate treatment.\u003csup\u003e4\u0026nbsp;\u003c/sup\u003eA recent write-up\u003csup\u003e5\u0026nbsp;\u003c/sup\u003esuggests useful screening practices for dentists regarding BDD and modifications to aesthetic dental treatment. Numerous authors have published similar findings and recommendations\u003csup\u003e6,7,8,9\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;No study was found which performs a clinical survey to assess the existing knowledge and practice among dentists on screening BDD patients. Furthermore, no systematic review or meta-analysis are available in this area. More structured research and studies will provide data required to fabricate an evidence-based set of guidelines on screening and managing BDD patients. As aesthetic dentists, these will be beneficial in the management of the aesthetically driven patient and potential identification of BDD prior to commencement of treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Aim \u0026amp; Objectives \u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eTo assess the knowledge and practice among dentists based in India, United Kingdom and Australia on screening patients with body dysmorphic disorder. \u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003ePrimary objective\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eTo assess the existing knowledge of dentists across India, Australia and United Kingdom on screening BDD patients in their respective dental practice.\u003c/li\u003e\n \u003cli\u003eTo understand present practice and understanding on dealing with BDD patients in respective clinical practice among above-mentioned cohort of dentists\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eSecondary objective\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eTo compare difference in knowledge and practice on dealing with BDD patients among different dentists based on age, experience, region of practice and degree/field of specialisation or formal training received\u003c/li\u003e\n \u003cli\u003eTo conduct a narrative literature review of the same\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Background","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eBody dysmorphic disorder-definition and understanding\u003c/h2\u003e \u003cp\u003eThe diagnostic and statistical manual on mental disorders (DSM-5) by the American Psychiatric Association describes body dysmorphic disorder (BDD) as an exaggerated preoccupation with a perceived bodily defect or severe concern wherein there is a mild/slight bodily defect often associated with excessive distress and functional impairments. The innate individual’s desire to look good and perceived to be attractive is a natural human trait. However, when this desire becomes pronounced, obsessive and exaggerated to the point of affecting one’s quality of life and functioning, it is referred to as dysmorphophobia/BDD.\u003csup\u003e1,2\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe International Classification of diseases (ICD-11) published by the World Health Organization's defines BDD as continuous persistent preoccupation with bodily defect(s) which may or may not be noticeable to other individuals. Individuals are convinced that they are being noticed/judged for these slight body defects.\u003csup\u003e10\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eClinical criteria\u003c/h2\u003e \u003cp\u003eThe affected individuals may spend greater than 3 hours per day obsessing over one or more body part over a minor/imaginary deficit. The body parts usually include skin, hair, nose but may change and involve 5–7 body parts over the course of the individual’s lifetime. The preoccupation with physical appearance may vary between 3–8 hours per day and is often associated with guilt, shame, anger and disgust. These feelings are not pleasurable and emotionally distressing for the patient.\u003csup\u003e11\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eBDD is often found to be associated with obsessive compulsive disorder and would include a clinical pattern of repetitive habits such as checking in mirror, skin picking, comparing appearance to others, seeking reassurance from others, grooming and so on.\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eBDD tends to impact the academic, social and occupational functioning of the affected individual making them inclined to become home-bound and adversely affect their quality of life. Patients may avoid intimate relationships and may even have a suicidal predilection.\u003csup\u003e13\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAs per the DSM the following diagnostic criteria are employed to diagnose BDD\u003csup\u003e14\u003c/sup\u003e-\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003ePreoccupation with an imaginary body deficit. If at all the deficit exists, it is mild and the person’s concern is excessive proportional to the degree of deficit.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe above-mentioned preoccupation causes significant impact on functioning of the individual in social, vocational, occupational and other roles of life.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThis cannot be attributed to another mental health disorder (such as anorexia, etc).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003cp\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePsychopathology and Aetiology of body dysmorphic disorder\u003c/h3\u003e\n\u003cp\u003eSocial, psychological, cultural and biological factors may play a role in the development of BDD. An impairment in the brain circuits frontal-striatal, temporo-parietal-occipital have been suggested which leads to hampered processing of facial images and emotions. The serotonin system may also play a role since the depletion of tryptophan has been associated with exacerbations in the symptoms of BDD.\u003csup\u003e14,15\u003c/sup\u003eA cognitive-behavioural model for BDD has also been proposed wherein the patient has an unrealistic ideal goal for appearance, excessive focus on self and negative perception of the body image. There may be some degree of overlap between BDD and other social disorders such as health anxiety, obsessive-compulsive disorder and social phobia. The individual enter a viscous cycle, they perceive themselves as aesthetic objects and negatively appraise the same leading to emotions of disgust, shame, rumination, depression and safety behaviour to camouflage the appearance to look ‘better’.\u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003eDemographic strata and prevalence of BDD\u003c/h3\u003e\n\u003cp\u003eThe global prevalence of BDD is estimated to be 2.2% among students, 1.9% among adolescent population and 3.3% among adult psychiatry settings. It was reported to be 13.2% in cosmetic surgery settings, 5.2% in orthodontics and cosmetic dentistry setting and 11.2% in orthognathic surgery. Overall, the prevalence was found to be higher in females compared to males.\u003csup\u003e17\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003ePractice-based prevalence studies in dentistry\u003c/h3\u003e\n\u003cp\u003eIn the dental setting, a study was conducted by Hepburn and Cunningham, 2006, in United Kingdom to assess the prevalence of BDD among 40 patients using the Yale Brown Obsessive Compulsive Disorder Questionnaire for Body dysmorphic BDD-YBOCS scale and found prevalence of 7.5% (males-6.3%, females-8.3%).\u003csup\u003e18\u003c/sup\u003e Another study by De Jongh et al, 2009 in Netherlands reported an overall prevalence of 4.1% among dental patients in aesthetic dentistry set-up.\u003csup\u003e19\u003c/sup\u003e A study in Iran [Yassei \u003cem\u003eet al\u003c/em\u003e, 2014] reported a prevalence of 5.2%.\u003csup\u003e20\u003c/sup\u003e The above-mentioned studies have been conducted among patients seeking orthodontics/aesthetic dental procedures. These findings suggest that approximately every 5–7 in 100 patients would be diagnosed with body dysmorphic disorder in aesthetic/orthodontic areas of dental practice. This leads us to reflect as aesthetic dentists that the prevalence is significant and should be screened for prior to initiating treatment planning in the interest of best practice for the patient and clinician.\u003c/p\u003e\n\u003ch3\u003eBDD and its impact in medical settings\u003c/h3\u003e\n\u003cp\u003eBDD will be discussed in the general medical settings first so its behavioural manifestations, screening protocols and treatment modifications may be extrapolated and better understood in the field of aesthetic dentistry.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDermatology\u003c/h2\u003e \u003cp\u003eIn the field of dermatology, BDD patients may be frequent visitors who are perpetually dissatisfied with the treatment received. The patient’s level of physical disfigurement does not correlate proportionally with grade of patient’s concern for the same. One third of the patients visiting the dermatology settings have a psychiatric illness. BDD is also a common condition which needs to be screened for and treated using a joint dermatological-psychiatric approach.\u003csup\u003e21\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCosmetic surgeries\u003c/h3\u003e\n\u003cp\u003eBDD patients often resort to unnecessary dermatological intervention or cosmetic surgeries.\u003csup\u003e22\u003c/sup\u003e Overall, the patient demand for cosmetic procedures is on the global rise. In the year 2015, a total of 21.9\u0026nbsp;million patients sought surgical/non-surgical cosmetic intervention globally.\u003csup\u003e23,24\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTherefore, the prevalence of BDD patients in these settings are also increasing. Some authors truly believe that patients of BDD have no positive outcome or benefit from undergoing cosmetic surgeries.\u003csup\u003e23,25\u003c/sup\u003e The practice of cosmetic surgeries on BDD patients without correction of underlying psychiatric impairment may lead to lawsuits/threats or even physical assaults from patients.\u003csup\u003e26\u003c/sup\u003e Some patients have severe BDD where the condition impacts social, day-to-day life with associated avoidant behaviour, anxiety, depression, self-mutilation (even do-it-yourself surgeries). Studies mentioned above suggest that these patients should not be taken up as candidates for cosmetic surgeries.\u003c/p\u003e \u003cp\u003eOther studies suggest that mild-moderate BDD patients with no impact on day-to-day functioning may be taken up for surgery with carefully nuanced decision-making as this gives the patients a newer perspective.\u003csup\u003e27\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003ePsychiatric settings\u003c/h3\u003e\n\u003cp\u003eBDD patients may undergo severe mental turmoil, distress and poor social and occupational life. They may suffer from higher suicidal ideations and a mean of 2.6% were found to attempt suicide per year.\u003csup\u003e28\u003c/sup\u003e It is essential to diagnose the underlying BDD since it may be masked by the associated co-morbid conditions. Psychiatric interviews and screening questionnaires serve as useful aids. Depending on the grade and severity, the psychiatrist prescribes cognitive psychotherapy, pharmacotherapy or a combination of the two. Overall, this is a lifelong illness, relapses-remissions are common.\u003csup\u003e29\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eGeneral Medical Settings\u003c/h2\u003e \u003cp\u003eThe prevalence varies between 5–13% depending on the setting, population and diagnostic criteria employed. Overall, these patients report to general primary care medicine with chief complaints pertaining to appearance. Even a brief interview may reveal their anxiousness, obsessiveness with physical defect which may not correlate to the size or magnitude of the same. The same should be screened, assessed and referred for suitable care ahead with note to referring physician.\u003c/p\u003e \u003cp\u003eA summary for the impact/trends of BDD across medical settings is tabulated. [Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBDD and its trends in various medical settings\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical Setting\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrevalence\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBDD implications\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eManagement recommendation\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDermatology\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.9–36%\u003csup\u003e30\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCosmetic dermatology, defects of skin on exposed areas e.g. face, like acne, scars, pigmentation, facial hair reduction, younger and female patients were found to be more predisposed. Skin picking may be a prominent feature\u003csup\u003e21\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eScreening, dermatological intervention where physician feels suitable, psychiatry treatment (adjunct)s\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlastic/ cosmetic surgery\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6–15%\u003csup\u003e31\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBreasts, buttocks, thighs, toes, facial hair surgeries, lip enhancement which may be of average/normal size others like fat reduction with higher women predilection\u003csup\u003e32\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRelative or complete contraindication to cosmetic surgery as management without correcting underlying psychiatric problem would lead to threat/lawsuit or even assault\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychiatry settings (in-patient/out-patient\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.5–15%\u003csup\u003e33\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eImpairment of social/occupational life, distress, suicidal ideation, comorbid with obsessive-compulsive disorder, eating disorder, social anxiety, unipolar depression,\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe underlying BDD tends to be masked by co-morbid condition, therefore careful diagnosis required, cognitive behavioural therapy, pharmacotherapy like selective serotonin reuptake inhibitors, tricyclic antidepressants, anxiolytics, serotonin-noradrenaline reuptake inhibitors.\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral medical settings\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5–13%, variable\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReport to primary healthcare settings with chief complaint regarding appearance, proportion of concern is much higher compared to volume of physical defect\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUsually, these patients are referred to dermatology/cosmetic surgery settings, ideally medical practitioners should be aware and screen/assess/refer suitably\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eBDD and its impact in dental settings\u003csup\u003e3,20\u003c/sup\u003e\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003eObsessive Concern/care for dental appearance\u003c/h2\u003e \u003cp\u003eThe patients may become persistently obsessed with any minor flaws in the gums, teeth or smile. This pattern may become so obsessive that it tends to have a detrimental impact on their day-to-day functioning and lives.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eAvoidant treatment patterns\u003c/h2\u003e \u003cp\u003eIn some cases, the fear of shame/guilt/self-conscious judgement may be so great that the patient avoids visits to the dentist/dental care altogether.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eNeed for aggressive dental treatment\u003c/h2\u003e \u003cp\u003eThese patients may request electively for dental treatment which may be irreversible and unnecessary. The procedures may even be radical and aggressive despite having healthy teeth and a physiologically healthy smile. Therefore, previously aggressive dental care may have already been delivered to such patients. A recent study [Kashan et al, 2021] demonstrated that among patients in oral surgery group opting for facial cosmetic surgery was highly predisposed (16.7%) to BDD.\u003csup\u003e34\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003ePoor treatment outcomes\u003c/h2\u003e \u003cp\u003ePatients with BDD may be constantly dissatisfied with the treatments received. They may have unrealistic expectations and look for perfectionism even away from reality perspective.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eRelevance of BDD for field of aesthetic dentistry\u003c/h2\u003e \u003cp\u003eBDD patients often request for dental whitening and orthodontic treatment procedures.\u003csup\u003e35\u003c/sup\u003e Another study demonstrated that over one third of the dental visits among BDD patients was for crowns and restorative work.\u003csup\u003e20\u003c/sup\u003e The patients tend to be visiting specialities of prosthodontics, orthodontics and aesthetic dentistry on a higher side as per a study in 2008.\u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eBDD is also found to have a direct correlation with the dissatisfaction related to dental procedures. Those who were found to have increased sensitivity to flaws were found to be more dissatisfied with dental treatments.\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eScreening questionnaires for BDD\u003c/h2\u003e \u003cp\u003eThe diagnosis of BDD is a nuanced one, the diagnosing physician/dentist needs to be attentive to basic cues. A verbal interview, questionnaires or a combination may be a thorough practice to screen for BDD patients among busy outpatient settings. A compilation of some useful screening tools is made in Table\u0026nbsp;2.\u003csup\u003e4\u003c/sup\u003e The diagnosis of BDD includes a more detailed assessment. The diagnosis may be done by means of BDDE (Clinician examination) questionnaire. In the dental settings, it must be employed prior to elective orthognathic surgeries. Another diagnostic tool is BDD (self-report) examination. Further a Structured Clinical Interview for BDD (SCID) is published which is time-consuming and usually utilised in psychiatric settings only. However, despite the presence of these tools in literature, there is no global consensus on mandatory screening for BDD by the average general dentist. The awareness and application may vary for each dental practitioner.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003ePresent literature and lacunae\u003c/h2\u003e \u003cp\u003e Despite rising pattern, prevalence and behaviours following body dysmorphic disorder in both medical and dental settings, there are no standardised guidelines for screening BDD patients in general or specialist dental practice.\u003c/p\u003e \u003cp\u003eThe knowledge and practice of dentists may be variable for the same globally depending on social, cultural and economic factors and type of dental practice. A study was performed among oral surgeons to assess their knowledge, attitude and practice on managing psychological issues among surgery patients. The study demonstrated low knowledge among 40% surgeons in United Kingdom wherein majority has no inter-disciplinary practice to refer patients to psychology care.\u003csup\u003e36\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThere is evidence to suggest that screening for BDD should be carried out in interest of patient satisfaction and doctor’s security prior to general aesthetic clinical procedures.\u003csup\u003e4\u003c/sup\u003e A recent publication [Rosten \u0026amp; Newton, 2020]\u003csup\u003e5\u003c/sup\u003e suggests useful screening practices for dentists regarding BDD and modifications to aesthetic dental treatment. Few literature reviews regarding the same are also available.\u003csup\u003e6–9\u003c/sup\u003e However, no study was found which performs a clinical survey to assess the existing knowledge and practice among dentists on screening BDD patients. Further, no systematic review or meta-analysis are available in this area. As aesthetic dentists, having a systemic set of guidelines on screening, management and guidance on care for BDD patients which is practical to inculcate in routine OPD settings would be useful. Further, for those dentists or areas which have poor existing knowledge on BDD or its screening, integration in dental curriculum and continuing dental education programs in this regard would be helpful.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eAim of present research\u003c/h2\u003e \u003cp\u003eTherefore, as stated above, the present study aimed to validate and administer a questionnaire to dentists to assess their knowledge and practice on screening patients with body dysmorphic disorder visiting their dental practice. Further, to compare difference in knowledge and practice on dealing with BDD patients among different dentists based on age, experience, region of practice and degree/field of specialisation or formal training received. Based on data available, the study reviewed the current understanding among dentists on screening and management of BDD in the field of aesthetic dentistry.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003ch2\u003eEthical Clearance\u003c/h2\u003e\u003cp\u003eThe study protocol was approved from the research ethics office, King’s College London under minimal risk registry. [MRSU-23/24-40858; 5/1/24]\u003c/p\u003e\u003ch2\u003eQuestionnaire fabrication\u003c/h2\u003e\u003cp\u003eA questionnaire was fabricated by the research team to assess the screening practices among dentists for body dysmorphic disorder. After informed consent was given, the survey collected data including: demographic details such as age, gender, area/country of practice, years of clinical experience and nature/field of dental practice.\u003c/p\u003e\u003cp\u003eThe survey included a 7-part questionnaire with graded Likert scales to assess the present awareness, screening practices (written/verbal), inclusion in university curriculum, continuing professional development (CPD) programs, referral protocols, litigation and practice-action on managing BDD patients. [Appendix 1-Study Questionnaire attached]\u003c/p\u003e\u003ch2\u003eParticipant Selection\u003c/h2\u003e\u003ch2\u003eInclusion criteria\u003c/h2\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003eDental practitioners with valid registration to practice with the relevant authorities in the location of: India, Australia and United Kingdom\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eGeneral dentists, general dentists with specialist registration and those enrolled in a formal certificate/diploma/degree program practicing in India, Australia and United Kingdom\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e\u003ch2\u003eExclusion criteria\u003c/h2\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003eDentists not actively practising clinical dentistry\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e\u003ch2\u003eRecruitment of Study Participants\u003c/h2\u003e\u003cp\u003eThe questionnaire was made using Google forms and Google workspace and circulated digitally. The dental practitioners in the countries: India, United Kingdom and Australia were sent the soft copy of questionnaire (hyperlink format). The dental practitioners in these regions were reached out thereby employing convenience sampling technique.\u003c/p\u003e\u003cp\u003eThe surveys were distributed to colleagues through professional social media groups, known dentist colleagues, faculty and alumni in India, United Kingdom and Australia. A total of approximately 300 dentists were sent the questionnaire. After attrition, 92 responses were received wherein 98.9% participants consented to fill the questionnaire.\u003c/p\u003e\u003ch2\u003eData Storage\u003c/h2\u003e\u003cp\u003eAll responses were saved in confidentiality with no sharing of data to any third party/person.\u003c/p\u003e\u003ch2\u003eData Entry and Statistical Analysis\u003c/h2\u003e\u003cp\u003eThe responses once obtained were entered and coded in Microsoft Excel 2019 (Excel 16.0) (2018) for ease of statistical analysis. The data responses were analysed using the SPSS software v23.0. The level of significance was kept at 5%. The demographics and details about BDD awareness, training and practice were presented using frequency and percentage. A comparison of the same between male and female dentists was made using the Mann-Whitney U test. The comparison of trends based of clinician experience, specialisation and area of practice was performed using the Kruskal Wallis test followed by Bonferroni test for multiple comparisons. The correlation of awareness towards BDD with practice and training was assessed with the Spearman rank correlation test. Since the responses to each question were ordinal in nature, non-parametric tests were applied for comparisons.\u003c/p\u003e\u003cp\u003e \u003cb\u003eKeyword search strategy\u003c/b\u003e \u003c/p\u003e\u003cp\u003eDue to non-homogeneity of available literature and lack of systematic reviews and randomised control trials in the area of body dysmorphic disorder in aesthetic dentistry, a narrative review of literature was performed. The available databases PubMed, Medline, Web of Science, Google scholar, OVID and APA PsycINFO were searched using keywords: body dysmorphic disorder, body dysmorph*, dymorphophob*, aesthetic dentistry, dentistry, dental, dental clinic, dent*, medical, awareness, screening, management, knowledge, practice separated by suitable Boolean operators AND, OR and NOT as appropriate in various permutations. The available literature was analysed to form a set of compiled information bank to study knowledge on screening and management on BDD in the field of dentistry in different regions of the world.\u003c/p\u003e"},{"header":"Study Results","content":"\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eDemographic details of participants\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic details of study participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean: 35.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSD: 12.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eExperience\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 years or less\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 to 10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003egreater than 10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eArea of work\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eCountry of practice\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eCategory 1: General dental practitioner who has completed formal certificate/diploma or degree in the field of in the field of aesthetic/restorative/ orthodontics or prosthodontics; Category 2: General dental practitioner who is pursuing/ completed formal certificate/diploma or degree in the field of oral medicine/paediatric dentistry/periodontics or maxillofacial surgery; Category 3: General dentist currently pursuing formal certificate/diploma or degree in the field of aesthetic/restorative/ orthodontics or prosthodontics; Category 4: General dentist without any formal specialist training working in government / private sector\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e describes the demographic details of the study participants. The participating dentists have a mean age of 35.27\u0026thinsp;\u0026plusmn;\u0026thinsp;12.64 years with 57.8% females and 42.2% males. The responses obtained from different regions included 62.2% participants from India, 20% from Australia, 16.7% from United Kingdom and 1% from United States respectively. The participants were further divided into categories based on area of experience/training and based on years into clinical practice.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eTrends on BDD screening /practice among dentists\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTrends on knowledge, screening and practice of BDD patients in dental practice\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuestion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOption\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eHow would you best grade your awareness towards Body Dysmorphic Disorder (BDD) and its implications in the field of aesthetic dentistry?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLimited Awareness (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBasic Awareness (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate Awareness (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh Awareness (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eDoes your practice have a set of screening questionnaires (like BDD questionnaire or similar others) employed prior to providing aesthetic dental work to patients?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot Implemented (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePartially Implemented (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerately Implemented (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFully Implemented (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eDid your dental university curriculum include any training on assessment of BDD or other psychological conditions among patients?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo Inclusion: not covered (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLimited Inclusion (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate Inclusion (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComprehensive Inclusion (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eHave you attended any continuing professional development course on BDD assessment for dental procedures?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo Attendance (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLimited Attendance (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate Attendance (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComprehensive Attendance (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eIs there any fixed protocol on how to provide a practice referral to the psychologist from the dental practice if required?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo Protocol (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInformal Protocol (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBasic Protocol (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEstablished Protocol (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eHave you/any colleagues you know faced any litigation from an aesthetic dental work done for the patient?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo Incidents (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRare Incidents (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate Incidents (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequent Incidents (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eIf a suspected/known case of BDD comes to your dental practice demanding for aesthetic work, what would the line of action be at present?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo Established Action (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLimited Awareness and Action (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBasic Action (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComprehensive Action (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarizes trends in Body Dysmorphic Disorder (BDD) awareness, training, and screening among dental practitioners. A large proportion of participants had limited (18.9%) or basic (32.2%) awareness of BDD, while only 14.4% reported high awareness. More than half of the respondents (50%) reported that BDD training was not included in their dental school curriculum, and 56.7% had never attended a professional development course on BDD. Notably, 45.6% of practitioners had no screening protocols for BDD, and 40% had no structured referral system to psychologists.\u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003eComparison of BDD Awareness and Practice by Gender, Experience, Specialization, and Location\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eComparison of BDD Awareness and Practice by Gender, Experience, Specialization, and Location\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"15\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuestion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;5yrs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6-10yrs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10yrs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCat 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCat 2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCat 3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCat 4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003eUK\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c14\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c15\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAwareness of BDD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(2\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e(2\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (1.25-3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (2\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 (2\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3 (2\u0026ndash;3)a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3 (1.25-3)a,b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(2\u0026ndash;3)a,b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2 (1\u0026ndash;2)b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e3 (2\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e2 (1.25-3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e2 (2\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e4 (4\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e0.016*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity Training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(1\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(1\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003cp\u003e(1\u0026ndash;2)a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (1\u0026ndash;2)a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (1\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (1-2.75)a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (1\u0026ndash;3)a,b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(1\u0026ndash;2)a,b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.5 (1\u0026ndash;2)b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2 (1\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e1 (1\u0026ndash;2)a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e2 (1\u0026ndash;2)a,b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e4 (4\u0026ndash;4)b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e0.037*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAction for Suspected BDD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(2-3.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003cp\u003e(2\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(1\u0026ndash;3)a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(2\u0026ndash;3)a,b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 (2\u0026ndash;4)b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3 (2\u0026ndash;4)a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3 (1.25-4)a,b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(2\u0026ndash;3)a,b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(1\u0026ndash;2)b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2 (2\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e2 (1\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e2 (2\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e4 (4\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e \u003cp\u003e0.012*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eMann Whitney test (male, female), Kruskal Wallis test(experience, category, location); Adjustments for multiple comparisons: Bonferroni test; * indicates a significant difference at p\u0026thinsp;\u0026le;\u0026thinsp;0.05; Different superscript letters (a,b) in a row indicates a significant difference between respective pair of groups; Category 1: General dental practitioner who has completed formal certificate/diploma or degree in the field of in the field of aesthetic/restorative/ orthodontics or prosthodontics; Category 2: General dental practitioner who is pursuing/ completed formal certificate/diploma or degree in the field of oral medicine/paediatric dentistry/periodontics or maxillofacial surgery; Category 3: General dentist currently pursuing formal certificate/diploma or degree in the field of aesthetic/restorative/ orthodontics or prosthodontics; Category 4: General dentist without any formal specialist training working in government / private sector\u003c/em\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e presents a consolidated comparison of BDD awareness and practice across gender, years of experience, specialization, and location. Awareness and practice varied significantly based on specialization, with practitioners trained in aesthetic/restorative/orthodontics reporting greater awareness than general practitioners without formal specialist training (\u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.016\u003c/em\u003e). Additionally, more experienced practitioners (\u0026gt;\u0026thinsp;10 years) demonstrated higher levels of structured action for suspected BDD cases compared to those with \u0026le;\u0026thinsp;5 years of experience (\u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.012\u003c/em\u003e). University training on BDD also differed significantly by location, with Australian and UK practitioners reporting higher inclusion compared to Indian practitioners (\u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.037\u003c/em\u003e). However, no significant difference between male and female dentists was noted.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation of knowledge/awareness towards BDD with practice and training\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003er-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAwareness vs Practice\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.475\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAwareness vs Training on Assessment of BDD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.547\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAwareness vs Attending a course on BDD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.446\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSpearman rank correlation test; * indicates a significant correlation at p\u0026thinsp;\u0026le;\u0026thinsp;0.05\u003c/p\u003e \u003cp\u003eThis table (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) presents the correlation of knowledge/awareness towards BDD with practice and training. There was a moderate positive correlation of awareness with practice and training of BDD.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis multinational survey conducted across India, the United Kingdom, and Australia revealed that most participating dentists exhibited only basic (32.3%) to moderate (34.4%) awareness regarding screening for Body Dysmorphic Disorder (BDD). Alarmingly, 45.6% lacked any structured protocol\u0026mdash;written or verbal\u0026mdash;for BDD screening within their practices. Additionally, over half of respondents indicated that BDD psychology and management were not included in their undergraduate curriculum, nor had they received any continuing education in this area. Furthermore, 40% reported having no defined referral protocol for patients suspected of having BDD. While nearly half had encountered medico-legal challenges, approximately one-third still operated without structured BDD protocols. This highlights a significant gap in professional readiness to manage psychologically vulnerable patients in aesthetic dental practice.\u003c/p\u003e \u003cp\u003eLimited practice-based studies have examined the prevalence of BDD in dental populations. A study in prosthodontic clinics found a 7% BDD prevalence with a female predilection, using the Dysmorphic Concern Questionnaire.\u003csup\u003e37\u003c/sup\u003e Alharbi \u003cem\u003eet al\u003c/em\u003e. (2023) reported a 34.1% prevalence in East Saudi Arabia using a culturally adapted screening tool.\u003csup\u003e3\u003c/sup\u003e Dutch data (de Jongh \u003cem\u003eet al\u003c/em\u003e., 2008) suggested higher BDD prevalence in cosmetic dental clinics compared to general practice.\u003csup\u003e19\u003c/sup\u003e Hepburn and Cunningham (2006) noted BDD was more common in orthodontic patients (7.5%) than the general population (2.86%) in London, with persistent dissatisfaction reported even after seemingly successful treatments.\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe current study found no significant differences between male and female dentists in their approach to BDD screening or management. While specific literature on gender-based BDD screening trends among clinicians is lacking, extrapolated data suggest females dental students may demonstrate heightened aesthetic perception, particularly in academic settings.\u003csup\u003e38,39\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDentists with over a decade of clinical experience reported more structured approaches to BDD management compared to those with fewer than five years in practice in the present study. While direct literature on experience-specific BDD handling is absent, studies on clinical judgment support the idea that experience enhances diagnostic acumen and strategic flexibility.\u003csup\u003e40,41\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAwareness and preparedness for BDD were higher among specialists in aesthetic dentistry, prosthodontics, and orthodontics compared to general practitioners. These clinicians demonstrated clearer management protocols, likely due to both advanced training and frequent patient exposure. Although literature on this correlation is sparse, observational reports suggest BDD is more commonly encountered in cosmetically oriented dental settings.\u003csup\u003e5,42\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe present study identified significant university curricular differences across regions. UK and Australian dental programs incorporated more comprehensive BDD-related content than Indian institutions. While screening practices showed minimal location-based variation, the disparity in educational infrastructure\u0026mdash;India having the highest number of dental schools globally\u0026mdash;may affect the depth of psychosocial training, including BDD recognition and management.\u003c/p\u003e \u003cp\u003eA moderate positive correlation was identified between a dentist\u0026rsquo;s level of BDD awareness and their quality of practice and training. This underlines the importance of educational exposure in shaping clinical confidence and preparedness for managing such patients.\u003c/p\u003e \u003cp\u003eA simple verbal screening prior to aesthetic, orthodontic, or restorative procedures is recommended for all dental patients. Domains to be explored include appearance concerns, behavioural avoidance, social functioning, preoccupation, and psychological distress. It is also noted by the authors that patients with a history of general medical cosmetic surgery, cosmetic dermatology may be more likely to have undiagnosed BDD and appropriate screening is recommended. Experienced clinicians may identify warning signals during patient interactions, reducing the need for formal questionnaires. This pre-screening is vital to safeguard both the patient\u0026rsquo;s mental health and the clinician\u0026rsquo;s legal and ethical responsibilities.\u003csup\u003e17,43\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eStandardised self-report screening tools like the Body Dysmorphic Disorder Questionnaire, Dysmorphia Concern Questionnaire and Cosmetic Procedure Screening Questionnaire are effective in identifying Body Dysmorphic Disorder (BDD), especially in dental and orthodontic settings where the condition is often under-recognised. These instruments assess core symptoms, distress levels, and severity, with proposed protocols\u0026mdash;such as the one by Polo et al. (2011)\u0026mdash;aiding clinicians in early detection.\u003csup\u003e44\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eEffective BDD management in dental clinics requires identification and early detection through systematic screening and detailed patient interviews. Key areas include the patient's primary complaint, emotional burden, external pressures, prior treatment history, and expectations. Screening for depressive symptoms, anxiety, and suicidal ideation is essential. Positive disclosures regarding self-harm warrant immediate psychiatric referral. Without awareness of BDD contraindications, dentists risk providing inappropriate care and facing legal consequences. A structured, informed approach supports both patient well-being and clinical safety.\u003csup\u003e6,26\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThere is ongoing debate about whether patients with Body Dysmorphic Disorder (BDD) should undergo cosmetic dental treatment. Most literature advises against any operative intervention due to high dissatisfaction rates and poor outcomes. Crerand et al. (2005) reported that 91% of BDD patients showed no improvement following aesthetic treatments.\u003csup\u003e45\u003c/sup\u003e These patients are prone to persistently seeking care from multiple providers, increasing the risk of complaints and medico-legal repercussions. Thus, referral to mental health professionals is widely advocated before considering any treatment. However, select cases of mild-to-moderate BDD with realistic expectations may benefit from carefully planned interventions.\u003csup\u003e27\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eReferral to psychologists or psychiatrists facilitates evidence-based care through cognitive behavioural therapy (CBT) and pharmacotherapy, particularly SSRIs. CBT aims to desensitise anxiety-provoking thoughts and restructure negative body image beliefs.\u003csup\u003e46\u003c/sup\u003e Only psychologically stabilised patients should be considered for any functional dental procedure.\u003c/p\u003e \u003cp\u003eLegally, BDD may impair decision-making capacity, invalidating consent in some cases. The UK\u0026rsquo;s General Dental Council (GDC) permits non-surgical aesthetic treatments like botulinum toxin for trained dentists but warns of increased litigation risk in BDD cases. Screening and careful patient selection are therefore essential.\u003csup\u003e26, 47\u003c/sup\u003e A summary of key considerations is depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBody Dysmorphic Disorder (BDD) affects an estimated 5\u0026ndash;7% of dental patients, particularly in cosmetic, orthodontic, and aesthetic practices. In this cross-national study across India, the UK, and Australia, 51.1% of dentists reported only basic or limited awareness of BDD, and 45.6% lacked any formal screening method\u0026mdash;verbal or written\u0026mdash;in their practice. Notably, 50% had no exposure to BDD within their undergraduate curriculum, and 56.7% had never attended continuing education related to BDD. Despite nearly half having encountered medico-legal issues, 40% had no defined protocol for psychological referral.\u003c/p\u003e \u003cp\u003eClinicians with greater experience or formal training in aesthetic disciplines demonstrated superior ability to identify and manage suspected BDD cases. No gender-based differences were found, though dentists from the UK and Australia reported stronger university training in BDD management compared to India. Routine verbal and questionnaire-based screening is recommended, especially for aesthetic procedures. Given the unique psychological needs of BDD patients, it is recommended that these issues be addressed before embarking on permanent and irreversible dental treatment. The authors recommend clinicians to have a protocol for the screening of potential BDD patients and a referral pathway for interdisciplinary assessment and treatment. The study advocates for the inclusion of BDD-related content in dental curricula and targeted continuing education programs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge statistical support from Dr. (Prof) Mahesh Khairnar. \u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are no conflicts of interest. \u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved from the research ethics office, King\u0026rsquo;s College London under minimal risk registry. [MRSU-23/24-40858; 5/1/24] \u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFunding Statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDr. Puja Sabherwal: \u003c/strong\u003eConceptualization, Methodology, writing, analysis, original draft, review and editing, data collection \u003cbr\u003e\u003cstrong\u003eDr. Michael Chan: \u003c/strong\u003eData Curation, Formal Analysis, Writing \u0026ndash; Original Draft, revision, review and editing, Supervision\u003cbr\u003e All authors read and approved the final manuscript.\u003c/p\u003e\n\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAmerican Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: Text Revision. 4th ed. Washington, DC: American Psychiatric Association; 2000.\u003c/li\u003e\n\u003cli\u003eSingh AR, Veale D. Understanding and treating body dysmorphic disorder. Indian J Psychiatry. 2019;61(Suppl 1):S131\u0026ndash;S135.\u003c/li\u003e\n\u003cli\u003eAlharbi A, Alkhathami A, Farooqi FA, Al-Khalifa KS, Shahin S, Nassar E, et al. The prevalence of body dysmorphic disorder and its associated risk factors among dental patients: Why are my patients not satisfied? Cureus. 2023;15(11):e49739.\u003c/li\u003e\n\u003cli\u003ePereira IN, Chattopadhyay R, Fitzpatrick S, et al. Evidence-based review: Screening body dysmorphic disorder in aesthetic clinical settings. J Cosmet Dermatol. 2023;22:1951\u0026ndash;1966.\u003c/li\u003e\n\u003cli\u003eRosten A, Newton T. Body dysmorphic disorder: A guide to identification and management for the general dental practitioner. Dent Update. 2020;47(4):303\u0026ndash;313.\u003c/li\u003e\n\u003cli\u003eScott SE, Newton JT. Body dysmorphic disorder and aesthetic dentistry. Dent Update. 2011;38(2):112\u0026ndash;118.\u003c/li\u003e\n\u003cli\u003eAhluwalia R, Bhatia NK, Kumar PS, et al. Body dysmorphic disorder: Diagnosis, clinical aspects and treatment strategies. Indian J Dent Res. 2017;28(2):193\u0026ndash;197.\u003c/li\u003e\n\u003cli\u003eKumar SS, Kudagi VS, Kaur G. Chasing perfection: Body dysmorphic disorder and its significance in dentistry. J Int Oral Health. 2018;10:157\u0026ndash;160.\u003c/li\u003e\n\u003cli\u003eJames M, Clarke P, Darcey R. Body dysmorphic disorder and facial aesthetic treatments in dental practice. Br Dent J. 2019;227(10):929\u0026ndash;933.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. ICD-11 International Classification of Diseases for Mortality and Morbidity Statistics. 11th Rev. Geneva: WHO; 2018.\u003c/li\u003e\n\u003cli\u003ePope CG, Pope HG, Menard W, et al. Clinical features of muscle dysmorphia among males with body dysmorphic disorder. Body Image. 2005;2:395\u0026ndash;400.\u003c/li\u003e\n\u003cli\u003ePhillips KA, Kaye WH. The relationship of body dysmorphic disorder and eating disorders to obsessive-compulsive disorder. CNS Spectr. 2007;12:347\u0026ndash;358.\u003c/li\u003e\n\u003cli\u003eAngelakis I, Gooding PA, Panagioti M. Suicidality in body dysmorphic disorder (BDD): A systematic review with meta-analysis. Clin Psychol Rev. 2016;49:55\u0026ndash;66.\u003c/li\u003e\n\u003cli\u003ePavan C, Simonato P, Marini M, et al. Psychopathologic aspects of body dysmorphic disorder: A literature review. Aesthet Plast Surg. 2008;32(3):473\u0026ndash;484.\u003c/li\u003e\n\u003cli\u003eGrant JE, Phillips KA. Recognizing and treating body dysmorphic disorder. Ann Clin Psychiatry. 2005;17:205\u0026ndash;210.\u003c/li\u003e\n\u003cli\u003eVeale D. Advances in a cognitive behavioural model of body dysmorphic disorder. Body Image. 2004;1:113\u0026ndash;125.\u003c/li\u003e\n\u003cli\u003eVeale D, Gledhill LJ, Christodoulou P, et al. Body dysmorphic disorder in different settings: A systematic review and estimated weighted prevalence. Body Image. 2016;18:168\u0026ndash;186.\u003c/li\u003e\n\u003cli\u003eHepburn S, Cunningham S. Body dysmorphic disorder in adult orthodontic patients. Am J Orthod Dentofacial Orthop. 2006;130(5):569\u0026ndash;572.\u003c/li\u003e\n\u003cli\u003eDe Jongh A, Oosterink FM, van Rood YR, et al. Preoccupation with one\u0026apos;s appearance: a motivating factor for cosmetic dental treatment? Br Dent J. 2008;204:691\u0026ndash;695.\u003c/li\u003e\n\u003cli\u003eYassaei S, Goldani Moghadam M, Aghili H, et al. Body dysmorphic disorder in Iranian orthodontic patients. Acta Med Iran. 2014;52:454\u0026ndash;457.\u003c/li\u003e\n\u003cli\u003eHerbst I, Jemec GBE. Body dysmorphic disorder in dermatology: a systematic review. Psychiatr Q. 2020;91:1003\u0026ndash;1010.\u003c/li\u003e\n\u003cli\u003eAnderson RC. Body dysmorphic disorder: recognition and treatment. Plast Surg Nurs. 2003;23:125\u0026ndash;128.\u003c/li\u003e\n\u003cli\u003eLee K, Guy A, Dale J, et al. Adolescent desire for cosmetic surgery: associations with bullying and psychological functioning. Plast Reconstr Surg. 2017;139:1109\u0026ndash;1118.\u003c/li\u003e\n\u003cli\u003eValikhani A, Goodarzi MA. Contingencies of self-worth and psychological distress in Iranian patients seeking cosmetic surgery: integrative self-knowledge as mediator. Aesthet Plast Surg. 2017;41:955\u0026ndash;963.\u003c/li\u003e\n\u003cli\u003eBouman TK, Mulkens S, van der Lei B. Cosmetic professionals\u0026apos; awareness of body dysmorphic disorder. Plast Reconstr Surg. 2017;139:336\u0026ndash;342.\u003c/li\u003e\n\u003cli\u003eSweis IE, Spitz J, Barry D, et al. A review of body dysmorphic disorder in aesthetic surgery patients and the legal implications. Aesthet Plast Surg. 2017;41(4):949\u0026ndash;954.\u003c/li\u003e\n\u003cli\u003ede Brito MJ, Nahas FX, Cordas TA, et al. Body dysmorphic disorder in patients seeking abdominoplasty, rhinoplasty, and rhytidectomy. Plast Reconstr Surg. 2016;137:462\u0026ndash;471.\u003c/li\u003e\n\u003cli\u003ePhillips KA, Menard W. Suicidality in body dysmorphic disorder: a prospective study. Am J Psychiatry. 2006;163:1280\u0026ndash;1282.\u003c/li\u003e\n\u003cli\u003ePhillips KA, Menard W, Quinn E, et al. A 4-year prospective observational follow-up study of course and predictors of course in body dysmorphic disorder. Psychol Med. 2013;43(5):1109\u0026ndash;1117.\u003c/li\u003e\n\u003cli\u003eBrohede S, Wyon Y, Wingren G, et al. Body dysmorphic disorder in female Swedish dermatology patients. Int J Dermatol. 2017;56(12):1387\u0026ndash;1394.\u003c/li\u003e\n\u003cli\u003eSarwer DB, Spitzer JC. Body image dysmorphic disorder in persons who undergo aesthetic medical treatments. Aesthet Surg J. 2012;32:999\u0026ndash;1009.\u003c/li\u003e\n\u003cli\u003ePhillips KA, McElroy SL, Keck PE, et al. A comparison of delusional and nondelusional body dysmorphic disorder in 100 cases. Psychopharmacol Bull. 1994;30:179\u0026ndash;186.\u003c/li\u003e\n\u003cli\u003eMcGrath LV, Oey L, McDonald S, et al. Patient satisfaction surveys in dental school clinics: a review and comparison. J Dent Educ. 2015;79:388\u0026ndash;393.\u003c/li\u003e\n\u003cli\u003eKashan DL, Horan MP, Wenzinger E, et al. Identification of body dysmorphic disorder in patients seeking corrective procedures from oral and maxillofacial surgeons. J Craniofac Surg. 2021;32(3):970\u0026ndash;973.\u003c/li\u003e\n\u003cli\u003eAlhammadi MS, Halboub E, Al-Mashraqi AA, et al. Perception of facial, dental, and smile esthetics by dental students. J Esthet Restor Dent. 2018;30(5):415\u0026ndash;426.\u003c/li\u003e\n\u003cli\u003ePitak-Arnnop P, Herv\u0026eacute; C, Coffin JC, et al. Psychological care for maxillofacial trauma patients: a preliminary survey of oral and maxillofacial surgeons. J Cranio Maxillofac Surg. 2011;39(7):515\u0026ndash;518.\u003c/li\u003e\n\u003cli\u003eP\u0026eacute;rez Rodr\u0026iacute;guez C, Judge RB, Castle D, Phillipou A. Body dysmorphia in dentistry and prosthodontics: a practice-based study. J Dent. 2019;81:33\u0026ndash;38.\u003c/li\u003e\n\u003cli\u003eAlthagafi N. Esthetic smile perception among dental students at different educational levels. Clin Cosmet Investig Dent. 2021;13:163\u0026ndash;172.\u003c/li\u003e\n\u003cli\u003eAbu Alhaija ESJ, Al-Shamsi NO, Al-Khateeb S. Perceptions of Jordanian laypersons and dental professionals to altered smile aesthetics. Eur J Orthod. 2011;33(4):450\u0026ndash;456.\u003c/li\u003e\n\u003cli\u003eDunphy BC, Cantwell R, Bourke S, et al. Cognitive elements in clinical decision-making: toward a cognitive model for medical education and understanding clinical reasoning. Adv Health Sci Educ Theory Pract. 2010;15:229\u0026ndash;250.\u003c/li\u003e\n\u003cli\u003eElstein AS. Thinking about diagnostic thinking: a 30-year perspective. Adv Health Sci Educ Theory Pract. 2009;14:7\u0026ndash;18.\u003c/li\u003e\n\u003cli\u003eEliyas S, Chana P, Briggs P. Complex dentistry in general practice\u0026mdash;What would you do? Prim Dent J. 2019;8(3):64\u0026ndash;74.\u003c/li\u003e\n\u003cli\u003ePerugi G, Akiskal HS, Giannotti D, et al. Gender-related differences in body dysmorphic disorder (dysmorphophobia). J Nerv Ment Dis. 1997;185(9):578\u0026ndash;582.\u003c/li\u003e\n\u003cli\u003ePolo M. Body dysmorphic disorder: a screening guide for orthodontists. Am J Orthod Dentofacial Orthop. 2011;139(2):170\u0026ndash;173.\u003c/li\u003e\n\u003cli\u003eCrerand CE, Phillips KA, Menard W, et al. Nonpsychiatric medical treatment of body dysmorphic disorder. Psychosomatics. 2005;46:549\u0026ndash;555.\u003c/li\u003e\n\u003cli\u003eIpser JC, Sander C, Stein DJ. Pharmacotherapy and psychotherapy for body dysmorphic disorder. Cochrane Database Syst Rev. 2009;(1):CD005332.\u003c/li\u003e\n\u003cli\u003eLewis K. Dento-legal aspects of non-surgical facial aesthetic procedures. Fac Dent J. 2014;5:68\u0026ndash;73\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Appendex 1","content":"\u003cp\u003eAppendix 1 is not available with this version.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7007371/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7007371/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eBody dysmorphic disorder (BDD) is a psycho-pathological condition which is on the rise particularly among young adults. These patients frequently visit the dental clinics for aesthetic, cosmetic and orthodontic interventions and pose a challenge to the unaware dental practitioner. Therefore, we conducted a study to assess the knowledge and practice among dentists based in India, United Kingdom and Australia on screening/managing patients with body dysmorphic disorder. Further the study aimed to compare these trends of existing knowledge based on clinical experience, speciality, gender and location and provide a review of literature to better understand this area.\u003c/p\u003e\u003ch2\u003eMaterials and methods\u003c/h2\u003e \u003cp\u003eA survey was undertaken amongst clinicians to assess current knowledge among dentists on BDD screening/practices. An online questionnaire was issued to approximately 300 dental practitioners via dental association groups, research recruitment university portals and social media groups/portals across India, United Kingdom and Australia. Ninety-two participant responses were received and analysed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA significant majority of the participating dentists recorded basic (32.3%) to moderate (34.4%) awareness about BDD screening. Overall, a substantial proportion (45.6%) of the dentists who received the survey globally reported lack of any defined written or verbal questionnaire in their practice to screen for BDD. Similarly, more than half the dentists surveyed did not study BDD psychology or its management in the university curriculum nor in continuing education courses. It was noteworthy that 40% of the participating dentists had no defined protocol on how to provide a psychologic referral for suspected or known patients of BDD. More experienced clinical practitioners and those specialising in aesthetic, restorative, or orthodontics had heightened awareness and management for BDD. Training for BDD was reported by dentists in UK and Australia to be more advanced when compared to India.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe authors recommend a universal management strategy when encountering any patients with psychological problems like BDD. The results advocate the use of screening both verbal and written questionnaire based is suggested during patient interview prior to treatment. Education and awareness are essential for enhancing dentist-patient outcomes in cases involving BDD, and for ensuring appropriate management.\u003c/p\u003e","manuscriptTitle":"Evaluating the Knowledge and Practices of Dental Practitioners in Screening Body Dysmorphic Disorder Patients in Aesthetic Dentistry: A Cross-Sectional Survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-08 05:52:51","doi":"10.21203/rs.3.rs-7007371/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cbe7b836-35da-4858-b8bb-0ac74bc86ea6","owner":[],"postedDate":"July 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":50947134,"name":"Health sciences/Diseases"}],"tags":[],"updatedAt":"2026-01-22T01:00:39+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-08 05:52:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7007371","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7007371","identity":"rs-7007371","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}