The Dentist’s Role in Treating Eating Disorders
Eating disorders are potentially life-threatening mental illnesses that can have devastating effects on a person's health and severely impact their quality of life if left unaddressed. They can affect people of all ages, sizes, shapes, ethnicities, gender, or socioeconomic groups. Early recognition and intervention help limit the physical and psychiatric consequences of these serious but treatable disorders and ensure better treatment outcomes.
As dentists, we hold a position of unique importance in the healthcare system that allows us to be able to detect and identify various medical health conditions in their initial stages by their oral signs and symptoms. With regard to eating disorders, dentists can often prove to be the first line of defense in suspecting a diagnosis by paying close attention to their oral manifestations, especially since most patients are reluctant to seek help for these issues.
To be able to correctly diagnose and act on the early signs of eating disorders and help patients receive the appropriate treatment they require, it is imperative that dentists have a good understanding of the clinical manifestations of these disorders and have the skill set to implement the right screening tools. Research studies have shown there to be a strong association between eating disorders and oral disease. Nutritional deficiencies and disordered eating habits can increase the risk of developing dental disease.
Listed below are the most common eating disorders:
Anorexia nervosa:
Anorexia nervosa is an eating disorder characterized by excessive calorie restriction out of extreme fear of gaining weight and abnormal perception of body image. Individuals who suffer from anorexia obsessively control their weight by either starvation, overexercising, or purging by either self-induced vomiting or misuse of laxatives.
During vomiting, the gastric acid from the stomach comes in contact with the teeth and causes severe tooth erosion and extreme sensitivity.
Bulimia nervosa:
This disorder is characterized by binge eating large amounts of food, followed by purging, in an attempt to get rid of the extra calories using harmful methods such as purging, self-induced vomiting, excessive use of laxatives, or enemas.
Self-inducing vomiting by inserting sharp objects in the mouth can damage the intraoral soft tissues and cause epithelial ulceration. In addition to that, generalized enamel erosion on the lingual surfaces of the upper anterior teeth, dental caries, dry mouth, and swelling of the parotid salivary gland are common oral findings in bulimic patients. The acidic level of the mouth largely depends on the kind of food that was consumed and the stomach acids being regurgitated to the oral cavity.
And the less common disorders, such as:
Rumination syndrome:
Rumination syndrome is a gastrointestinal disorder characterized by the involuntary repeated regurgitation of undigested food from the stomach to the mouth. Once it's in the mouth, the person may ingest it again or spit it out.
If left unaddressed, it can damage the esophagus causing unhealthy weight loss and malnutrition. It also has negative effects on the oral cavity as it causes enamel erosion and bad breath.
It causes less harm to the teeth, however, compared to other eating disorders. This is because the regurgitated food isn’t as acidic as vomit, since it hasn’t been mixed with the stomach acids and digested.
Pica:
This is an eating disorder that’s more common in children and pregnant women and is characterized by the repetitive eating of non-food items such as ice, chalk, paper, and dirt. It can be dangerous if any hazardous or toxic matter is swallowed. The proposed causes for this disorder are many and include various nutritional deficiencies, stress, mental health conditions, and other conditions such as pregnancy and sickle cell anemia.
If pica goes unnoticed long-term, it can lead to deleterious complications including choking, parasitic infections, bowel obstruction, perforation, ulcers, and heavy metal toxicity (such as lead poisoning). It may also damage the teeth and cause tooth erosion, tooth decay, noncarious cervical erosion, and tooth fracture (as a result of chewing on hard substances).
The Oral Manifestations of Eating Disorders
Early diagnosis and interception of oral signs by the dentist can bring about a significant improvement in the interception and prognosis of eating disorders.
Here’s a comprehensive list of the effects that eating disorders can have on oral health:
Tooth erosion and increased sensitivity
- The main cause of tooth erosion is the self-induced vomiting common in patients with eating disorders. The gastric acid from the stomach comes in contact mostly with the palatal surfaces of maxillary teeth and the occlusal surfaces of mandibular teeth, weakening them tremendously. As the enamel continues to wear away, the tooth structure keeps getting weaker and renders the teeth more prone to cracks and fractures. It also considerably heightens the sensitivity of the teeth to hot and cold foods.
- In addition to that, people with eating disorders typically opt for carbonated drinks containing artificial sweeteners to cut back on calories. These drinks make matters worse for your oral health by elevating the risk of tooth erosion.
Xerostomia
- Dry mouth occurs due to a hypofunctional salivary secretory process and is more common in bulimic patients.
- It results as a consequence of malnourishment and the medication taken to treat eating disorders, such as anxiolytics and antidepressants.
Salivary gland swelling
- The parotid salivary gland is most affected in this case. Frequent vomiting makes the gland swell up by being overstimulated and begins producing excessive saliva.
Dental caries and tooth loss
- These conditions are prevalent in people with binge eating disorders due to excessive
consumption of sugar and carbohydrates.
- Dental caries may also initiate as a result of dry mouth as it lowers the oral pH and
increases the susceptibility to decay and developing gum disease.
Periodontal disease
- There are not enough reliable data available to establish a strong link between eating disorders and periodontal disease. However, some studies do report an increased prevalence of gum issues, such as gingivitis, periodontitis, and gum recession in patients suffering from eating disorders.
Abrasion and attrition
- Since most individuals who suffer from eating disorders are emotionally and mentally disturbed, there is a high likelihood that they clench their teeth when stressed. Bruxism can cause tooth wear and result in dental attrition and abrasion.
Noncarious cervical erosion
- Self-inducing vomiting brings the gastric acid from the stomach in contact with the teeth
and cause enamel erosion, especially in the cervical areas of the teeth.
Halitosis
- The continuous regurgitation of stomach acid into the mouth creates an oral malodor that won’t go away with toothbrushing and other oral hygiene efforts. Starvation can also contribute to bad breath as it leads to the breakdown of certain chemicals in the body and cause halitosis.
Effects on oral soft tissues:
The soft tissues of the mouth are also greatly affected by the behavioral habits that accompany these life-threatening but treatable disorders.
Erythema
- Erythema of the soft tissues of the mouth results mainly from the chemical irritation caused by vomiting when the gastric fluids from the stomach are introduced into the oral cavity.
Ulcers, especially on the soft palate and pharynx
- Ulceration results from the mechanical irritation of the oral mucosa triggered by attempting to provoke vomiting with the use of sharp objects or fingers.
Atrophic lesions, including atrophic tongue
- Stress can be a cause for the onset of bruxism, which in turn can make the patient bite down on the tongue and possibly injure it.
Angular cheilitis
- Angular cheilitis is caused by vitamin deficiencies, decreased electrolyte levels, chronic dehydration, and general metabolic changes that are common findings in these patients due to repetitive and frequent purging.
What causes these effects in the oral cavity?
Most of the oral changes that occur subsequent to the onset of eating disorders stem from self-induced vomiting. However, the nutritional deficiencies that result from long-term calorie restriction (as in the case of anorexia) and the metabolic changes that follow, the compromised personal hygiene and poor eating habits, and the medication taken to treat these disorders all contribute to the damaging oral effects.
How can dental professionals help?
Dental teams are ideally positioned to pick up eating disorders during regular dental checkups that would otherwise go unnoticed. Dentists, dental hygienists, nurses, and therapists carry out routine dental exams that comprise a thorough inspection of the hard and soft tissues of the mouth. Early detection of these disorders is crucial to prevent complicated health issues.
Make the patient feel comfortable
It’s often easy for dental professionals to recognize the signs of an eating disorder during an oral exam. What’s difficult, however, is tackling this issue without making the patient feel humiliated or threatened. Addressing this concern in a way that exhibits thoughtfulness, kindness, and genuine interest in their overall well-being is of prime importance when it comes to matters like these. Providing the patient with an environment in which they feel comfortable is essential to help them open up and talk about their health. It is a sensitive topic that most patients are hesitant to talk about. Try not to label the patient with terms that sound too negative such as ‘bulimic’ or ‘anorexic’. Instead, consider phrasing your questions in a way that doesn’t make them offended or get defensive about their condition. For example, ask them if they’ve recently been throwing up a lot instead of if they have an eating disorder. Another way to go about this would be by presenting their oral clinical findings to them, say, for instance, dental erosion. Mention all the possible causes of tooth erosion, including frequent vomiting. This gives them a chance to talk about their eating disorder.
Some patients may understand your concern and be curious to find out more. If that is the case, use this as an opportunity to discuss with them the oral findings of your examination and the dental complications of disordered eating, in detail, and then refer them directly to an eating disorder specialist. However, you may not always be so lucky. If you feel that your patient is easily upset when talking about their condition, the best course of action would be to refer them to their primary care doctor without trying to probe their symptoms further. You can also prove to be supportive and helpful to them by teaching them how to prevent the dental issues that you’ve noticed they have.
Use a screening tool
There are various screening tools available that can easily be adopted in the dental setting. One that’s most widely used to identify eating disorders is the SCOFF screening tool. It is an acronym outlining five important questions regarding eating habits and can be remembered through the mnemonic: Sick, Control, One Stone, Fat, and Food.
The questions are listed below:
Do you make yourself sick because you feel uncomfortably full?
Do you worry you have lost control over how much you eat?
Have you recently lost more than one stone (14 pounds) in a three-month period?
Do you believe you are fat when others say you are too thin?
Would you say that food dominates your life?
An affirmative response equals one point. A score of two or more points indicates the presence of an eating disorder.
Educate patients
Oral health education plays a massive role in providing patients suffering from eating disorders with a supportive environment to help them overcome their fears and empower them to take better care of their oral health. When patients understand the damage caused by their disordered eating, it motivates them to seek help and take better care of themselves.
Educating patients about the oral complications of disordered eating and nutritional deficiencies and teaching them how to cope with and improve their oral health can benefit them greatly. For example, telling them how self-induced vomiting can cause their teeth to erode and cause problems or why their salivary gland swells up when they purge too much can make them aware of the dental implications of their illness. Informing them that the swelling will most probably subside if they break the habit of self-induced vomiting will encourage them to try and resist the urge to purge after eating. The more they learn about their condition and its impact on oral and general health, the more inclined they will be to seek help.
Clinical interventions
Xerostomia
The management for xerostomia is mainly symptomatic and focuses on relieving symptoms and preventing complications. Dentists can advise the use of salivary substitutes and stimulants, mucosal lubricants, and fluoride dentifrices. Xylitol has proven to be an effective saliva stimulant and your patients can reap its benefits by taking it in the form of gum, candy, or brushing with xylitol toothpaste. Emphasize the importance of staying hydrated at all times.
Dental caries
It is not advisable to do any permanent restorations for a person who’s currently purging as the intensely acidic environment will harm the restorations and shorten their lifespan. Only the most urgent restorative work, such as existing non-reversible carious lesions, must be completed. This should be sufficient enough to relieve the patient of pain and restrict the damage to the tooth structure.
Hypersensitivity can be relieved by applying non-abrasive fluoride varnishes and products containing calcium and phosphate (in an attempt to encourage remineralization and decrease sensitivity). The patient can also be prescribed fluoride gels or rinses to use at home. Patients must also be educated to limit their consumption of cariogenic food and drinks.
Halitosis
Halitosis is caused by sulfur-producing bacteria that release large amounts of odorous volatile sulfur compounds. The strategies employed to treat halitosis aim to reduce the overall bacterial load in the oral cavity. They include the treatment of carious lesions and periodontal infections, encouraging good oral hygiene habits (tongue scraping and flossing), and the use of antimicrobial agents (such as chlorhexidine). Sulfur compounds can be neutralized by using mouthwashes containing chlorine dioxide and zinc.
Tooth erosion
Dietary counseling of the patient is the most important step when it comes to controlling the negative effects of tooth erosion. The oral pH must be neutralized to try to control the incidence of dental caries. Patients should be instructed to avoid acidic food and drinks and stay hydrated to maintain a good salivary flow. Adequate fluoride exposure is vital in these patients to stave off decay. Mouthguards may be useful in protecting the tooth surfaces during episodes of self-induced vomiting. Brushing right after vomiting is a bad idea. The stomach acid weakens the tooth enamel and brushing it will just lead to more damage. Recommend swishing the mouth with plain water after throwing up instead.
The Bottom Line
When armed with a thorough understanding and solid skills to observe and detect the oral signs of an eating disorder, we, as dentists, can prove to be a great help to those struggling with these illnesses. Early recognition is key to ensuring improved treatment outcomes. Although the treatment for these disorders is outside the scope of a dental practice, we can play our part by educating the patients about its oral implications and providing them with preventive and therapeutic oral care.
