Dentists, fillers and body dysmorphic disorder

by Facial aesthetics, Mental health

The Irish Sunday Times ran a piece about dermal fillers at the weekend that captured the growing concern among medical professionals about body dysmorphic disorder (BDD).

With the market booming thanks to a desire among young people for fuller lips and cheeks to post on Instagram, where do responsible practitioners draw the line? Dentists are the natural responsible gatekeepers in a dangerous world and should be outspoken about their ethical position.

Kerry Hanaphy, a registered nurse who runs a cosmetic clinic that handles 100 lip fillers a week told the Sunday Times she was turning away more business because she didn’t want to encourage body issues. She said: “I go to conferences, training and masterclasses, and the biggest topic of conversation now is body dysmorphic disorder.

“That is what we have to look out for every time we speak to someone. We spend more time on the consultation now than we ever did. Young girls have a lot of body issues because of Instagram. I’m turning more and more business away because I want to be able to sleep at night.”

James Cotter, a doctor who provides fillers at his Sisu chain of five clinics, said it was once rare to see patients with substandard fillers, but in the past two years it has become increasingly frequent, “easily once a month”. He said that young women were “very price sensitive”.

“Typically they’re girls of 19 or 20 who got them done in a hairdresser’s or beautician’s. Sterilisation is not observed, there’s poor hygiene, and cheap products are used. We see people with lumps and bumps and poor cosmetic results, but the more extreme cases are infection, or the blood vessels in the lip have been compromised.”

Louise Clarke, a chartered psychologist, told the paper that social media pressure could trigger existing symptoms of BDD, and regulation of fillers was now “imperative” to ensure proper screening for the disorder. “For vulnerable people with BDD, injectables can be a surgical starting point,” she said.

But regulation hasn’t happened, and meanwhile some beauticians are linking their services to popular brands like Juvederm by tagging it on Instagram photos of their patients. Allergan, the manufacturer of Juvederm, says it sells the product only to “doctors, dentists and nurses in the UK and Ireland”.

Regulation could happen in Ireland next year as EU rules come into force in May. The Department of Health and the Health Products Regulatory Authority (HPRA) say the rules represent an opportunity to restrict supply, possibly bringing fillers under prescription control, and there may be ways to bring the administration of fillers under tighter control. Health officials are are examining whether an age limit is warranted.

But nothing is guaranteed. It is currently legal to give the service to under-18s, and anyone can administer fillers, which is why beauty salons, nail bars and hairdressers across Ireland and the UK offer them, many operating from home or visiting clients in their homes. Filler and numbing cream can be easily and legally bought online.

In the UK the Joint Council for Cosmetic Practitioners (JCCP), a voluntary trade body, has published guidelines on use of social media by registrants. Its members are expected to refuse treatment to patients with suspected BDD and refer them to NHS services. But just one in ten people offering non-surgical procedures are covered by the code.

NHS England medical director, Professor Stephen Powis, wrote to Superdrug after it announced it would begin offering Botox and dermal fillers on the high street, suggesting safeguards.

As a result the cosmetics chain now offers mental health screening to customers who come in for lip fillers and Botox. They are asked to complete a questionnaire developed by psychologists, and where BDD or other anxieties are identified they are directed to a GP or mental health groups.

Superdrug says assessments are undertaken by qualified aesthetic nurse practitioners and last an hour. The questionnaire asks customers if there are parts of their bodies they are anxious about, how often they look at these parts and how their anxiety interferes with their day to day activities. There is a 14 day cooling off period before patients can get treatment and an age restriction of 25.

BDD is thought to affect around one in 50 people, and charities say that facial aesthetics do not address their image concerns and could exacerbate them.

Fortune Business Insights predicts the global hyaluronic acid based dermal fillers market will be worth $4,884.6m by the end of 2026, up from $2,680.9m in 2018, rising at a compound annual growth rate of 7.8%.


“Dentists should be outspoken about their ethical position.”


Author: Jonathan Fine