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Among many reasons why healthcare systems have not inherently “evolved into safety” were the combination of provider individualism and the lack of early recognition of the importance of effective communication and coordination as the primary method of ensuring maintenance of safety standards throughout the entire patient care continuum [1]. The first two volumes of the Vignettes in Patient Safety focus on the development of patient safety champions [2] and the continued quest toward “zero error” performance across modern health systems [3].
\nAs our clinics, hospitals, and more recently growing networks of facilities began to aggregate providers from diverse disciplines and training backgrounds, the need for better coordination and communication to ensure safe and seamless patient care became apparent [3, 4]. Growing teams of highly trained individuals who work together, yet may not know each other, became the reality of healthcare systems that require the performance of multistep tasks of great complexity [5, 6]. In this introductory chapter, we will discuss how team communication and appropriate coordination of care are instrumental to ensuring and improving patient safety, as well as to the overall functioning of the patient safety matrix across healthcare organizations (Figure 1).
\nIdealized diagram summarizing key components of patient safety matrix in health care. Only selected components are listed, emphasizing the importance of good leadership, communication, and team coordination, in addition to other domains previously discussed in the Vignettes in Patient Safety.
The Institute of Medicine (IOM) defined six key measures to improve the overall quality of our healthcare system, including safety, effectiveness, timeliness, efficiency, equity, and focus on the patient [7]. The concept of patient safety has been an active area of opportunity for hospitals [8] and clinicians, especially with the advent of objective scorecards and pay-for-performance measures [3, 7]. Patient safety began to transform into its current, more structured format in the early 1990s as it became increasingly apparent that hospitals were not as safe as previously thought and patients undergoing treatment at our healthcare facilities were shown to be at substantial risk of adverse events [4, 9]. The field of healthcare quality and safety encompasses numerous factors, most of which have been discussed in previous volumes of this series, including topics like leadership and organizational culture [3]. In this volume we will explore in greater detail key patient safety concepts in the context of team communication and coordination. It is only through appropriately coordinated work as a team, using proven communication techniques, that we can bring tangible benefits to new and existing healthcare platforms, making care delivery safer, and establishing greater trust in the current system [10, 11, 12, 13]. Our exploration will emphasize the importance of teamwork in achieving the goals of the IOM and ultimately creating a universal and standardized environment and a culture safety (Figure 2).
\nKey components necessary for the creation of institutional culture of safety.
Historically, the practice of medicine has revolved around a personal interaction between the patient and his or her healthcare provider [14]. This viewpoint has permeated the cultural and organizational perceptions within medicine, thus heavily influencing and shaping the delivery (and effectiveness) of care [15, 16]. Even with the changing institutional and work dynamics within the healthcare system, this individualistic paradigm continued to prevail, with physicians treating patients at the point of care, characterized by only limited collaboration and coordination with other healthcare professionals [17, 18]. The transition from a physician-centered system to a more patient-centered system required a paradigm shift that inherently led to increased care complexity and the need for better coordination and communication across multidisciplinary teams [7, 19, 20]. There is ample evidence linking adverse healthcare events with inadequate team communication and/or coordination, highlighting the critical nature of “teamwork” as opposed to the more traditional and flawed “individual blame” culture [4, 5, 21, 22]. Patient safety literature also indicates that teamwork is key to establishing and maintaining patient safety, and issues related to lack of collaborative approaches and/or communication often contribute to poor quality and safety record [21, 23, 24]. Support for constructive and collaborative thinking must permeate all levels of the organization [3, 4]. At the same time, we must recognize that effective teamwork and collaboration are not going to be inherently easy within a dynamic, complex, and unpredictable environment of modern healthcare systems. However, the above limitation should not serve as a perpetual excuse for failing to improve the current status quo, as proven by other high performance or high-stakes industries that have successfully adopted effective quality, safety, and reliability models [4, 25, 26].
\nThroughout the Vignettes in Patient Safety series, we continually emphasize the importance of teams, communication, and the presence of dedicated champions critical to promoting a culture of safety throughout our institutions. In an attempt to present the reader with practical information and actionable knowledge, we also focus on clinically relevant elements of implementing effective team approach including strong leadership and communication and describing key aspects of a robust organizational culture of safety. This volume of The Vignettes will be specifically devoted to the importance of team communication and coordination as inextricable elements of a safe and efficient modern healthcare environment.
\nPatient safety can be defined as a discipline or characteristic of a healthcare system that focuses on the application of safety science methodologies to minimize the incidence and impact of adverse events, with the ultimate goal of creating a trustworthy and highly reliable healthcare delivery environment [9]. The critical importance of patient safety has been well established across the full spectrum of modern healthcare settings, including the more recent introduction of patient-centered care and quality-based reimbursement paradigms [3, 27, 28]. As the care delivery paradigm continues to evolve, we must strive to learn, grow, and make sustained improvements across all domains of practice, from the most mundane to the most complex ones. Because the focus on patient safety has its genesis in the combined desire and duty to “do the right thing” in conjunction with the realization that there is an unacceptably high prevalence of avoidable adverse events, we must all join forces and make the effort to meaningfully contribute at the personal, team, and institutional levels [3, 29, 30].
\nFor any meaningful change in practice (and thus organizational culture) to occur, a shift in mindset must be embraced at both individual and institutional levels [31]. In the past, there was a widely held belief that “well-trained and conscientious” providers generally do not commit errors and that most errors occurred because of “carelessness and incompetence” [9, 32]. Consequently, punitive approaches to error identification and correction prevailed, creating an environment of “fear, secrecy, and nondisclosure” [4, 9]. The resultant “culture of blame” gradually gave way to a more in-depth understanding of medical errors, with increasing realization that only a minority of errors are clearly attributable to a single individual or factor [3, 4, 5].
\nResearch into human factors provides evidence that in great majority of cases it is not “the individual” who is to be blamed, but rather the error results from imperfections within the organization’s systems, training, equipment, and/or management [9, 33, 34]. This sparked a transition toward system-based thinking and adoption of error management, an effective method used in aviation, into health care as a way of introducing a more sustainable paradigm change [3, 4, 35]. Subsequent identification and improved understanding of various “failure modes” such as “latent failures” that may be “hidden” within an otherwise highly efficient and safe environment [35] gave us further insight into phenomena “we did not know that we did not know.” Among various areas of scrutiny, it became apparent that the largest number of opportunities for improvement resided within the general domains of “team communication” and “team coordination” [36, 37].
\nFor the purposes of our discussion, a team is described as one or more individuals working together toward a specific, shared aim [21]. This highlights the importance of any verbal or written communication between providers and caretakers where at least two individuals are involved, regardless of how trivial such communication may seem at the time. Also, integral to the team context, each individual has a special role to play within their own area of knowledge and expertise [21]. Inherent to effective teamwork, individuals should be willing to share their resources, communicate and coordinate closely in order to provide the very best care and experience for the patient from every conceivable standpoint, including clinical outcomes, quality, and safety [21]. Of note, the above statements describe nearly every team-based microsystem within the modern healthcare construct.
\nIt seems that coordination and collaboration should be occurring intuitively in a high-performing medical system. However, breakdowns in communication, an essential element in care coordination, were found by The Joint Commission to contribute to 70% of adverse events [32], with a large proportion of these events resulting in mortality [38]. Teamwork is paramount not only to the development of a safe patient environment but also to improved patient outcomes, enhanced quality of care, and greater provider satisfaction [32, 38]. Inefficient team structure and poor functioning have been implicated in inferior quality of care and worse safety performance [21]. Given the complexities of modern healthcare environment, including the diversity of roles and increasing degree of specialization within essentially every area of practice/expertise, the above considerations become even more urgent [39, 40]. Consequently, the concurrent presence of well-choreographed coordination, communication, and teamwork is no longer optional in the interprofessional environment of modern health care, at all levels of every organization [40].
\nWhen people work together toward a common goal, remarkable achievements are possible. There are, however, important team-specific considerations. With the growth of team size and complexity, so does the potential for errors. Essential to reducing the number of errors is the presence of robust, often redundant feedback mechanisms [4, 41, 42]. In addition to improving safety and effectiveness of teams, properly structured teamwork may also help improve staff well-being and morale [21]. Consequently, targeted restructuring of microsystems and processes toward a more team-based approach can bring about important benefits and synergies [21]. Finally, thoughtful implementation of interventions that foster shared decision-making, planning, and problem-solving can also be effective in improving both clinical outcomes and patient safety [32].
\nAlthough healthcare professionals tend to be aware of the importance of teamwork, communication, and coordination, this awareness does not universally translate into appropriate or optimal behavioral manifestations [21]. As a result, breakdowns in teamwork—rather than lack of knowledge or clinical skills—continue to contribute to a significant proportion of adverse healthcare events [21]. Thus, the importance of working effectively within a complex team-based environment cannot be overstated, with evidence from one observational study conducted in the pediatric surgical setting demonstrating that “…effective teamwork was associated with fewer minor problems per operation, higher intraoperative performance and shorter operating times” [21]. If coordinated teamwork and communication are so important to ensuring patient safety, what are some of the more common failure modes and more importantly the associated barriers?
\nWithout effective communication between care providers, healthcare teams, and their patients, considerations given to safety measures are more likely to be insufficient, often creating adverse outcomes in both unexpected and unpredictable ways [6]. There are several important barriers to collaboration, coordination, and communication, as outlined in the current section. Within the highly complex and dynamic modern healthcare organizations, each individual must organize and coordinate the necessary care in accordance to their unique, specialized, and highly valued training, expertise, and patterns of practice [43]. Consequently, this inherent systemic heterogeneity is a strong determinant of breakdowns in team function, beginning with differences in the level and type of training and ending with vast and often non-overlapping skill sets that are neither universally understood nor well communicated across the involved group. For example, nurses and doctors are trained to communicate very differently. Nurses tend to be more detailed and emphasize gathering, collecting, and communicating highly granular facts [44, 45]. On the other hand, physicians are taught to interpret these facts, make a diagnosis, and communicate their conclusions without necessarily relating all of the details that led to the formulation of associated clinical plans [44, 45]. An important consideration in this general context is the potential difference in perceptions related to communication among different group members [45, 46].
\nAnother barrier to effective collaboration and communication is the persistence of hierarchical systems that place various team members at different levels of the team decision-making process, often based on specialty, expertise, politics, and other arbitrary factors [47]. Instead, approaches that embrace the fact that each individual brings a unique perspective and breadth of knowledge to the team should be encouraged and appear to be of great importance to improving patient outcomes and promoting a culture of safety [3, 4]. Inviting input and open discourse from the entire team can both improve the delivery of care and reduce the possibility of critical safety steps being missed. Mutual respect, appreciation, acknowledgement, and constructive reflection within the team must be encouraged and should constitute the foundation of sound organizational culture [48, 49]. Great emphasis also needs to be placed on valuing different perspectives, regardless of how divergent individual views may be, through respectful discourse and acknowledgment of key differences. In health care, each member of the team inherently believes that he or she is doing what is truly best for the patient. Respect for differing opinions is an important part of avoiding unnecessary “ego contests” that may be detrimental not only to the team dynamic but also to patient safety and outcomes.
\nThere are several other potential barriers to communication and collaboration that are worth mentioning. Intimidation and disruptive behavior both can interfere with effective coordination of care. There should be “zero tolerance” for these phenomena because they can lead to the development of a hostile work environment and result in fear of communicating or reporting medical errors (e.g., unwillingness to speak up). Any evidence of intimidation or retribution should be a basis for disciplinary action, up to and including termination of employment. Disruptive behavior has been associated with preventable adverse events and adverse patient outcomes [50], and it can distract team members from focusing on effective communication and the performance of essential functions of their job [32, 51]. In summary, it is critical that these two major, yet uncomfortably under-recognized barriers to effective team collaboration and communication be identified and aggressively addressed at all levels of healthcare institutions.
\nMuch like effective communication, highly structured coordination is important to ensuring that established patient safety mechanisms continue to function properly. All team members should be “on the same page” in terms of their understanding of the group’s function and purpose. Yet, as we discussed in previous sections, this can be challenging at times due to the abovementioned barriers. In this context, resistance to change may be responsible for the reluctance of both people and institutions to embrace better ways of doing things. Such resistance can persist within clearly dysfunctional teams despite unequivocal evidence demonstrating successful culture shift within other high-stakes industries such as aviation and banking [52]. Identification of problems in the current patient safety paradigm must begin with clear and unambiguous definitions. For example, there are different categories of suboptimal communication, including poorly timed, misdirected, incomplete or inaccurate information exchanges, as well as ineffective communication due to lack of follow-through [32]. The latter type is thought to be a leading cause of medical error and patient harm in the acute care setting [32]. As outlined throughout the Vignettes in Patient Safety cycle, the goal of effective communication should be to ensure that everyone’s understanding of the situation at hand is clear and that all participants are communicating in an organized, methodical fashion. This can be accomplished by standardizing the approaches which we use to relate critical information within and between healthcare teams. Thus, efforts to disseminate universally agreed upon clinical communication tools across our organizations will be of pivotal importance (as well as the efforts to educate all stakeholders accordingly). Multidisciplinary rounds are a great platform for coordinating care, ensuring that “everyone is on the same page,” fostering open communication and collaboration among different disciplines, and providing a troubleshooting forum for any problems that may arise [53].
\nStandardized team training is important to ensuring a sustained ability of our institutions to function at high-performance levels. Such training programs increasingly take into consideration the human performance science and are designed to mitigate errors and patterns of errors that commonly occur when human beings operate under high levels of stress [54]. Targeted training in leadership, decision-making, briefings, and cross-checking, as well as monitoring, reviewing, and modifying plans under stress, is integrated into the curricula [54]. Simulation constitutes another important aspect of team training. It provides an opportunity to practice various techniques and scenarios in a controlled, highly structured environment. It facilitates real-time feedback and thus creates an opportunity to proactively improve team attitudes and behaviors.
\nGood leadership is paramount to organizational success. Rapidly evolving modern healthcare environment requires leaders to be highly flexible and well-versed in change management skills, with focus on the delivery of high-quality, safe patient care. The establishment of a culture of safety is critical to the leadership’s ability to bring about institutional change, enhanced quality of care, and ultimately better patient outcomes [3, 4, 8]. Moreover, healthcare leaders must make patient safety a top organizational priority [8], and through such prioritization, a positive “trickle-down” effect will help gradually facilitate the desired institutional transformation. High-reliability organizations (HRO) can be defined as being able to successfully implement changes required to make them more efficient, safer, and cost-effective. This, in turn, exemplifies the “big picture” view of value-driven health care.
\nOrganizational culture defines the parameters of the work environment. For each healthcare institution and system, poorly managed variability within and between individuals, teams, departments, etc. has the potential to create a dangerous mix of both active and latent systemic contributors to patient safety events. In order to reconfigure the culture of an organization, not only does it takes broad-based staff buy-in but also effective leaders who are able to inspire individuals and teams to pursue both personal and operational excellence.
\nPatient safety is a dynamically evolving discipline, with many challenges and opportunities along the journey to operational excellence, just culture, and sustained “zero defect” performance record. The overarching theme of this chapter and this book is that effective teamwork requires the investment of significant amounts of time, effort, and energy by all stakeholders. Modern healthcare requires safe and efficient teamwork, which in turn requires intensive training and education. Most people find it challenging to work with large, complex teams and are often unaware of the various barriers to effective communication and coordination required to thrive in such environment. The creation of team-based healthcare systems must begin with breaking “old habits” and proactive advocacy for the adoption of modern, evidence-based approaches. Beginning with institutional leadership’s vision and strategy, trust and respect are fostered to help encourage positive behaviors and implement just culture. The ultimate goal of “zero harm” must always remain the top priority within the safer and more efficient healthcare systems of tomorrow.
\nMost people are not completely satisfied with their appearance. But some individuals are very concerned about a slight or imaginary flaw in their appearance. These individuals could have a “problem” not only physically but also psychiatrically.
Body dysmorphic disorder (BDD) is a condition not only in which a person overestimates and exaggerates a body defect but also one may believe in the existence even if there is not a body defect. This engagement can lead to significant unrest or impaired functionality. BDD is a severe illness and relatively common which often presents to both mental health professionals and nonpsychiatric physicians [1].
The disorder was defined as “compulsive neurosis” in the first place. After, it was called “obsession with shame of the body” and “dysmorphophobia,” respectively. Dysmorphophobia is preferred to explain the sudden emergence and continuation of the idea of a deformity; it is defined as an individual’s fear of the occurrence of this deformity and feeling the anxiety of this awareness considerably [2]. Body dysmorphic disorder was first shown in the DSM-IV in 1980 and described as an atypical somatoform disorder [3]. The American Psychiatric Association (APA) classified this “problem” as a distinct somatoform disorder in 1987, and since then it has gained popularity in the media and in clinical researches [4]. Currently, BDD is included in contemporary classification systems with DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition), the classification system of the APA [5].
The changes between DSM 4 and DSM 5 criteria for diagnosing BDD are shown in Figure 1. On the other hand, many tests have been established to diagnose BDD or measure its severity. However, some tests are performed more frequently for specific reasons, such as easy application and providing more effective results, for example, the Body Image Disturbance Questionnaire (BIDQ) [6], Yale-Brown Obsessive–Compulsive Scale Modified for BDD (BDD-YBOCS) and Body Dysmorphic Disorder Questionnaire (BDDQ) [7], the Cosmetic Procedure Screening (COPS) questionnaire [8], the Appearance Anxiety Inventory (AAI) [9], BDD Dimensional Scale (BDD-D) [10], the Body Image Disturbance Questionnaire (BIQLI) [11], and the Dysmorphic Concern Questionnaire (DCQ) [12].
DSM-IV to DSM-V body dysmorphic disorder comparison.
BDD is a relatively common disorder. Despite its prevalence and severity, the diagnosis can be missed in clinical settings [13]. The majority of BDD patients first consult dermatologists, internists, surgeons, and more often plastic surgeons, rather than psychiatrists. Therefore, it is difficult to determine the prevalence of this disorder in the psychiatric society. Although the studies in the general population range from 0.7 to 5.3% [14, 15, 16, 17, 18], clinical studies reveal higher rates: 8.8 to 12% [19, 20] among dermatology patients; 7% in cosmetic surgery patients [21]; 14–42% in patients with atypical major depression [22, 23, 24]; 11–13% in patients with social anxiety [25, 26]; 8–37% in patients with obsessive–compulsive disorder [26, 27, 28]; and 39% in patients with anorexia nervosa [29].
Despite the presence of BDD cases beginning in adulthood or childhood, symptoms often begin in adolescence or young adulthood [30]. In particular, men and young people do not want to report their complaints because of humiliation and embarrassment or do not see them as a mental problem. Although the age of onset goes down to 6 years, in many studies the age of onset is reported to be between the ages of 15 and 20, with an average age of 16–18 [31].
The main cognitive feature of BDD is the belief that extreme anxiety and imagined defect represent a personal disability. One’s quality of life can vary considerably. Many people can at least limit their social functions and resort to avoidance in order to prevent their imperfections from appearing fully in the public sphere. These avoidance strategies may include camouflage by wearing makeup or concealed clothing. Some individuals may never leave the house. Phillips et al. reported that men with BDD had a higher rate of single or single living than women, whereas another study found that 30% of BDD patients were individuals who could not leave their homes at least 1 week before the study [32, 33]. Other compulsive behaviors are to examine, heal, or conceal the perceived defects and include excessive mirror control, excessive care, styling hair, camouflaging the defect, comparing oneself with others, picking skin, and trying to convince the ugliness of the defect to others [34]. Therefore, psychosocial functioning of BDD is associated with suicidal tendencies and especially poor quality of life [35].
Although BDD was classified as a somatoform disorder in DSM-IV, it is currently accepted as a disorder of the obsessive–compulsive spectrum disorders (OCSD) group because of its overlapping aspects with OCSD in DSM-V. However, it is frequently emphasized that BDD not only is a clinical variant of OCSD but is also associated with mood disorders, social anxiety disorders, and eating disorders [36].
The main clinical features of BDD are disproportionately dealing with an imaginary or mild physical defect, which leads to significant clinical distress or a significant loss of functionality in work, private, and social life. It is known that most patients with BDD do not consult with psychiatrists and apply to nonpsychiatric physicians, such as esthetic surgeons, to eliminate the perceived physical defects. Sixty eight to ninety-eight percent of BDD patients experience concerns about multiple body regions [32, 37].
BDD may be related to the appearance of a body part or may sometimes arise from concerns about a body function. Sweating and related thoughts about the secretion of bad odor can be given as an example. Concerns of BDD cases become more apparent in social settings. Avoidance behaviors such as being unable to go out of the house or going out in the dark only, not being able to enter social environments due to concerns, and leaving school or work are common symptoms. Most of the patients believe that their physical defects are seen and noticed by others, and therefore they look at the mirror in excessive levels or try to stay away from the objects that reflect the mirror image as much as possible, make use of makeup material, and make dress changes in order to hide the areas that they believe to be defective.
The most common comorbid diagnoses in BDD are major depression, social phobia, drug addictions, and OCD [38]. Phillips et al. showed that the frequency of OCD was 37% among 100 cases [39], and similarly the incidence of OCD was found to be 39% of the study of 50 cases by Hollander et al. [37].
Because BDD and OCD have similar features in many respects, BDD is often accepted as an OCD [40, 41, 42]. However, poorer insight than OCD, higher suicide rates, and higher comorbidity of depression differentiate the two disorders [41, 43, 44]. A significant proportion of patients diagnosed with BDD show avoidance behaviors in social settings. This situation evokes the avoidance behaviors of social phobic patients [43]. Social phobia cases are comfortable as long as they stay away from crowded environments that cause anxiety for them.
Social phobia patients also know that their concerns are meaningless, but they cannot resist their anxiety. While individuals with BDD do not think their concerns are meaningless, staying away from social settings does not reduce the anxiety of such patients. Also, in social phobia, the reason for staying away from the social environment is not usually exaggerated physical defects [13, 35].
Many individuals with BDD resort to nonpsychiatric medical and surgical treatments to correct perceived defects in their physical appearance. Dermatological treatment is the most desirable and applied treatment (mostly acne agents). It is followed by surgical treatment, most commonly rhinoplasty. In a study in which 12% of subjects received isotretinoin, treatment rarely increased BDD. Therefore, nonpsychiatric medical treatments do not seem to be effective in the treatment of body dysmorphic disorder. Crerand et al. stated that individuals were also evaluated, and the results reported that individuals who refused psychiatric treatment did not observe any change and their condition worsened [45]. The somatic subtype of delusional disorder needs to be distinguished from BDD. The somatic subtype of delusional disorder provides more benefits than antipsychotic medication; BDD patients benefit from treatment with selective serotonin reuptake inhibitors (SSRIs) [38, 41]. The general opinion is that the use of high-dose SSRIs in BDD will be beneficial [46, 47]. The use of SSRI is considered to be the ideal treatment when the highest dose recommended by the manufacturer for 12 weeks or more is used. Daily fluvoxamine 150 mg, fluoxetine 40 mg, paroxetine 40 mg, sertraline 150 mg, citalopram 40 mg, and escitalopram 20 mg SSRI doses are considered as the minimum and adequate doses [48]. Any treatment of “defect” in patients with BDD is controversial. However, the general idea is that surgical treatments should be performed if only these individuals still need surgery after psychiatric treatment [49].
Due to almost all the scales being prepared in English, the translation of those forms into other languages and validity and reliability studies should be performed, and it must be proven that it is equivalent to the original language. For example, the translation of the YBOCS-BDD scale into Brazilian Portuguese was performed among 93 selected rhinoplasty patients of both sexes. Also, the test–retest method was used for reliability at 1-week intervals, and statistical analysis was performed using correlation coefficient and intraclass correlation coefficient (ICC) [50]. It has also been translated into Persian, German, French, and Italian, and these studies have shown significant results [51, 52]. In the German reliability and validity study of the BIDQ-S scale, which is a modification of the BIDQ scale for scoliosis patients, 259 patients with idiopathic scoliosis were included in the study [53].
The developed scales have been mentioned in many studies in the world, including esthetics such as dermatology, esthetic surgery, maxillofacial surgery, and orthodontics, and have been used to detect individuals with BDD (Figure 2). But the maxillofacial region is highly associated with face deformities, and the patients with BDD are applying to those clinics even without self-awareness of their disorders. Particularly, orthognathic surgery, also known as corrective jaw surgery, is considered functional surgery in the treatment of maxillomandibular dysfunction. However, the correction of maxillomandibular deformity creates highly esthetic and satisfactory results. In the studies in the literature, it has been reported that 52–74% of orthognathic surgical patients are associated with the facial appearance of surgical motivations and will have similar psychological motivations to cosmetic surgery patients. After this type of surgery, satisfaction with the outcome is as high as 92%, resulting in improved quality of life [54, 55, 56]. In a small number of patients (<10%) who are not satisfied with the surgical outcome, the underlying cause may be a psychological condition experienced by the individual rather than a failed surgical procedure. The underlying psychological condition may be BDD, which is believed to be increased in patients seeking orthognathic surgery [56]. It was found that 10% of orthognathic surgery patients met significantly higher BDD criteria than reported rates (between 0.7 and 4.0%) in the general adult population [15, 57, 58, 59]. This rate is similar to the prevalence of cosmetic surgery and dermatology patient population of BDD, which is between 6 and 16% [60].
Nonpsychiatric departments where body dysmorphic disorder patients generally apply to.
Although researches on BDD and dental treatment are relatively rare, published case reports showed the BDD patients involved in general dentistry and maxillofacial surgery. Some authors applied a questionnaire to 40 adult patients who participated in orthodontic treatment and estimated the prevalence of BDD to be 7.5%, suggesting that individuals with BDD had a high demand for orthodontic treatment [34]. De Jongh et al. reported the frequency of occupation of individuals with a defect in their appearance and stated that the rate of whitening and orthodontic treatment of those who reported that they were engaged in such defect was nine times higher [60]. These studies have shown that clinicians working in esthetic dentistry are likely to be visited by BDD patients and therefore need to be aware of the condition of such patients and to know how to evaluate and manage patients suspected of having BDD [49].
In addition to areas such as plastic surgery and dermatology, another important part where the patient comes with esthetic complaints is dentistry. Maxillofacial surgery, orthodontics, prosthetic, and restorative dental treatment, which is a branch of dentistry, are among the important parts that patients come with esthetic complaints. The inability to detect individuals with possible BDD in these departments and to try to eliminate the esthetic complaint before the treatment of psychiatric disorder adversely affects the success of the treatment.
Eventually, all of those studies show that the prevalence of BDD among dentist individuals is much more severe than the general population. Moreover, the incidence of BDD patients among individuals who apply to clinics is unknown. To increase the success rate of the treatment by increasing the satisfaction rate obtained as a result of the esthetic treatments, further studies should be planned to identify the individuals with BDD. The importance of informing the patients preoperatively in dentistry/maxillofacial surgery must be well-known. The studies should aim to increase the frequency of application of the tests for BDD in dentistry to determine the real epidemiology of this disease among this field.
The patients with BDD apply to all clinics to relieve their esthetic concerns which are the main complaint despite the lack of self-awareness of the psychological disorder.
These clinics may be dental, maxillofacial surgery, dermatology, and esthetic surgery that provide esthetic treatment to a large extent.
Worldwide research on BDD has not yet received the value it deserves concerning the prevalence and severity of the disease.
Researches in dentistry and oral and maxillofacial surgery are much less than in other departments. Individuals suffering from BDD are not well-known among dentists/oral and maxillofacial surgeons; therefore, the frequency of BDD patients is not noticed.
None.
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