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A review of the eating disorders literature with reference to dentistry Dental Update 2024 14:3, 707-709.
Abstract
Eating disorders are severe psychiatric illnesses associated with physical and psychological morbidity and mortality. In the UK, around 1 in 9 people are directly affected. Oral healthcare professionals may be among the first to observe the signs and symptoms of an eating disorder because of the recognizable and consistent links with oral pathology and it is important that they are sufficiently informed about the condition, and feel confident in raising it with patients and/or their families.
CPD/Clinical Relevance: Oral healthcare professionals may be among the first to suspect that a patient has an eating disorder: they can play a role in diagnosis and appropriate referral, as well as providing appropriate oral healthcare advice.
Article
In the United Kingdom, over 700,000 people, or around 1 in 9, currently have an eating disorder1 – a severe psychiatric illness associated with physical and psychological morbidity as well as mortality.2 Because symptoms of eating disorders may manifest internally and externally to the oral cavity and mucosa, dentists may be among the first to suspect the presence of an eating disorder in an individual.3,4,5,6,7
In 2009, the annual incidence rate (new cases) of eating disorders in the UK was around 37/100,000,8 with the condition being diagnosed more frequently in women than in men, although incidence is increasing for both.8,9 The American Psychiatric Association (APA) defines the diagnostic criteria for eating disorders with specific reference to anorexia nervosa (AN), bulimia nervosa (BN) and a range of other disorders, including the much less common binge eating disorder (BED), avoidant/restrictive food intake disorder (ARFID), other specified feeding or eating disorder (OSFED) and unspecified feeding or eating disorders (UFED) (Table 1).10
Anorexia nervosa
Restricted energy intakeSeriously low body weightIntense fear of gaining weightPersistent lack of recognition of seriously low body weight
Bulimia nervosa
Recurrent binge eating (eating, within 2 hours, an amount of food larger than most people in similar circumstances)Lack of control of eating during binge episodesRecurrent inappropriate behaviour to prevent weight gain (vomiting, laxatives, diuretics, fasting or excessive exercise)Self-evaluation is unduly influenced by body shape and weight
Binge-eating disorder
Recurrent, frequent episodes of binge eatingThree or more of the following: eating rapidly until uncomfortably full; eating large amounts of food although not hungry; eating alone due to embarrassment of quantity, feeling disgusted, depressed or very guilty afterwardsBinge eating not associated with the recurrent use of inappropriate compensatory behaviours
Avoidant/restrictive food intake disorder
Persistent failure to meet appropriate nutrition or energy needsSignificant loss of weight, nutritional deficiency, dependence on nutritional supplements, impaired psychosocial functioningNo evidence of a disturbance in the way in which body weight or shape is experienced
Other specified feeding or eating disorder
Causes clinically significant distress/impaired functioningAtypical anorexia: as above, but weight is within or above normalBinge eating disorder: as above, but less frequentBulimia nervosa: as above, but less frequentPurging disorder: recurrent purging behaviour to influence weight/shape in the absence of binge eating Night eating syndrome: recurrent episodes of night eating, after waking from sleep/excessive consumption after the evening meal
Unspecified feeding or eating disorder
Behaviours cause significant distress or impair function, but do not meet the criteria listed above
Although the immediate image of an eating disorder that springs to mind may be associated with AN (someone who has an inaccurate perception of their body shape and size, who is malnourished and who monitors food intake either by restriction, inappropriate vomiting or laxative use and/or by exercising intensively or excessively) eating disorders can take other forms. People with BN may have a normal weight and body mass, but are likely to binge eat and then compensate either by vomiting, using laxatives or exercising intensively.7,11,12 The other disorders defined by DSM V10 may comprise some, but not all, of the characteristics of AN and BN, and all are likely to cause significant distress to the individual, impair daily functioning and have adverse impacts on their health.13 Outcomes are generally better for adolescents with an eating disorder than for adults8 and for people with BN rather than AN.14
According to the 2013 BDA report,15 dentists see, on average, around 24 patients each day. Therefore, those working for eight sessions each week (~96 patients) may expect, on average, to see around one patient per week with an eating disorder. There is evidence that many oral healthcare professionals (OHCP) do not assess their patients for eating disorders. They report that they do not have adequate training about the condition, are concerned about probing sensitive issues with patients or their family members and that they perceive barriers to referral networks (eg no protocols). There is an additional challenge in patients' tendencies to deny that anything is wrong.11,16 Given that OHCPs may be among the first to observe the signs and symptoms of an eating disorder owing to recognizable and consistent links with oral pathology,5,17,18,19 it is important that they are sufficiently informed about the condition, and feel confident in raising it with patients and/or their families.
Aetiology and impact on general health
Eating disorders have a complex aetiology and often appear to be the result of an interaction between biological, sociocultural and psychological or cognitive factors. Consequently, influences from both nature and nurture are associated with eating disorders, and the greatest genetic impact occurs around the time of puberty and in adolescence. The peak age of onset in the UK is between 15 and 19 years for women; it varies for men, but can start as early as 10 years of age.8
In the western world and in developed countries, there is currently a social idealization of ‘being thin’,14,20 and we regularly read that visual images of models and celebrities are airbrushed to remove ‘imperfections,’ including physical mass (eg making sure that women have an unnatural gap between their thighs).7,21 In addition, children and young people face increased pressures about image, perfection and weight control from overprotective and/or hypercritical families, peers and other interpersonal relationships.14,15 In dysfunctional families, where there is little physical contact and high levels of criticism or indifference, children are also at increased risk of an unnatural relationship with food, and they may show a tendency to manipulate diet and exercise excessively to manage their weight. There is also increased evidence of a genetic influence from twin studies22 and their psychological and physiological impacts. These include: (1) increased inhibitory control (inhibition of natural behavioural responses, such as eating when hungry); (2) cognitive inflexibility (an inability to be flexible when processing thoughts and concepts associated with appropriate behavioural responses23); and (3) observed changes in the neurotransmitters and hormones circulating in the blood.14 Around 1 in 8 young people will have experienced personal exposure to an eating disorder by the time they are aged 20 years and between 15% and 47% admit to disordered thoughts and behaviours around food and exercise.24 Around 5% progress to a diagnosis of a full-threshold disorder such as AN or BN, and another 12% may be diagnosed with other eating disorders;24 yet more others experience many adverse effects of disordered eating on their health without being diagnosed.13
Impact of eating disorders on health
General health
The medical complications that arise from disordered eating, excessive exercise and purging behaviours may be physical or mental and can affect any system or organ in the body.20 Most can be resolved with re-feeding and resolution of purging, but there are some (including the impact on dentition), which become irreversible over time.9
People who have an eating disorder may have a wide range of physical medical conditions including emaciation, ‘unexplained’ weight loss, hypotension, bradycardia, cyanosis, stunted growth, menstrual irregularities and ovarian changes, sleep problems, lethargy and fatigue, sore throat and callouses on the knuckles (Russell's sign) due to putting the fingers down the throat to prompt vomiting.14 They may feel guilty and ashamed and, therefore, may not easily disclose the origin of their health issues even if they do seek healthcare.16
Improve awareness of sources of acid in the diet
Reduce intake of low-calorie fizzy drinks and fruit juice; always use straws to drink
Reduce fruit consumption, especially citrus fruits
Reduce alcohol intake
Oral hygiene
After vomiting, rinse mouth with water or milk, chew gum
Brush teeth gently with small amount of bicarbonate/desensitizing toothpaste after vomiting
Regular flossing and dental visits
Medication
Check that medicines do not cause dry mouth or vomiting
Prescribe artificial saliva or saliva pastilles for dry mouth/salivary hypofunction
Poor mental health may also be associated with poor diet and increased sugar intake (eg comfort eating, reliance on easily prepared readymade meals) and is associated with oral symptoms such as xerostomia and caries in around 61% of those affected;13,14 side effects associated with prescribed medications may also be responsible for oral symptoms.25 Given the association between oral health and self-esteem, this can rapidly turn into a vicious circle with both poor oral health and poor self-esteem having a reciprocal effect on each other, together with an adverse effect on quality of life.13,26
Oral health
The impact of eating disorders specifically on oral health is wide-ranging,26,27 and may be observed between 6 months and 2 years after the start of caloric restriction or vomiting.7 People who try to manage their caloric intake, either by vomiting or with high intake of fizzy drinks or citrus fruit, are likely to have dental erosion associated with an acid environment4,6,27 rather than bacterial action, as well as decalcification and destruction of the tooth enamel and dentine.
There is some, as yet inconclusive, evidence that these oral health symptoms may also be a function of xerostomia or a change in salivary profile (salivary stones may also be present in severe cases).18,26 Erosion due to purging is most likely to be observed on the lingual, palatal (incisors, canines and premolars) and occlusal surfaces (molars, premolars), and its severity will be a function of the frequency of vomiting and subsequent oral hygiene practices. In contrast, those who restrict intake by eating lots of citrus fruits will be more likely to display erosion on the buccal surfaces.3,14,27,28 The adverse impact of increased intake of acidic drinks and fruit may well be greater in people undergoing orthodontic treatment with fixed appliances, because the excess acids will gather around the brackets.7
Some authors report an increased risk of caries in people with eating disorders,4,5,17,18,27 but others suggest that the perfectionist tendencies often associated with eating disorders (especially with AN) will generalize to oral hygiene practices and, therefore, there will be no increased risk of caries.14 Alternatively, the high fat intake associated with BN may be protective against caries, but is likely to have an adverse effect on the plaque index of the individual.4
Other adverse oral outcomes of restricted eating or purging behaviours include dry or cracked lips, swollen parotid glands, symptoms associated with temporomandibular disorders (TMD), such as dizziness, headache, facial pain, aching jaws and sleep disturbance, distractibility and sleeplessness.11 The association with TMD signs and symptoms may arise from the mechanical pressures exerted during self-induced vomiting. Periodontal disease is rare in people with EDs, again likely to be due to perfectionist oral hygiene tendencies, but where it is observed, it is often a side effect of vitamin C deficiency due to a restricted diet.11 Oral infections, such as angular cheilitis and glossitis, may occur because of poor nutrition, and there is often a high prevalence of streptococci, lactobacilli and oral yeasts (candidosis), especially in people with BN.2,4,14
Managing the oral health of people with eating disorders
Given the prevalence of eating disorders in the general population, it is important that dentists understand their aetiology and how they present.14 However, people with EDs are reported to be reluctant to visit the dentist,29 and, even if they do, some dentists complain that they have little knowledge and clinical experience of EDs generally,16 and little awareness of the physical manifestations/complications of EDs associated with oral health.11
The first clinical sign of an eating disorder may be dental erosion.4 In one study, 70% of people with self-induced vomiting presented with enamel or dentine erosion, most with at least five teeth affected,6 although the association between erosion and eating disorders is not linear.14 Other symptoms that may manifest over time or be reported during a dental history include teeth that are sensitive to hot and cold, more general oral discomfort or pain, a poor appearance for anterior teeth (perhaps changes to tooth morphology and colour7), soft tissue lesions if spoons or other instruments are used to induce vomiting,29 functional difficulties when chewing or biting3 and an adverse impact on oral health-related quality of life.26
Such symptoms, especially if they appear together, may be due to frequent and prolonged vomiting, unnatural diets and/or the effects of wasting and dehydration associated with starving,17,18 but, additionally may arise from vigorous and frequent toothbrushing after exposure to stomach acid through self-induced vomiting.6 While these symptoms are undoubtedly some of the adverse effects of eating disorders, it is important that differential diagnoses be considered rather than assuming that they are due to poor diet, side effects of medication or excessive intake of fizzy or sugary drinks.26
Having a conversation about eating disorders
The dentist should take sensitive social, medical and dental histories using a sympathetic and non-judgemental approach.14 S/he should also be prepared to act upon suspect findings by contacting parents or carers if the patient is under the age of 16 years and agrees to that contact. Similarly, after discussion with the patient and/or with parental consent, OHCPs should be prepared to refer appropriately to either a GP, nurse or counsellor from the Child and Adolescent Mental Health Services (CAMHS).2 Dentists and DCPs should, however, be aware that patients may initially deny disordered eating behaviours, or be slow to disclose, so that any such discussion is likely to be difficult.30 If done sympathetically, mirrors and intra-oral images can be used to support a worrying hypothesis3 together with sensitive but persistent questioning as appropriate.
After disclosure the dentist needs to communicate effectively about sensitive oral and health issues and, in so doing, try to identify and address underlying causal factors.30 In order to treat the patient, it may be that prolonged conservative and restorative treatment will be required, but the practitioner will need to elicit and understand the patient's wishes regarding their health and treatment options (ie facilitate patient autonomy) and also be sympathetic, while avoiding paternalism. A motivational interviewing framework34 can be helpful in such situations (Figure 1), facilitating consultations where the patient's needs and concerns are met appropriately, depending on their strengths and aspirations, and readiness/motivations to change.30,34
Figure 1. The EAT Framework: how to manage a patient with eating disorders (adapted from reference 30).
Appropriate oral hygiene advice is also important. For example, people with eating disorders should be encouraged to use straws to drink sugary liquids, and to rinse the mouth with water or milk or chew gum to neutralize the gastric acid after vomiting, instead of brushing immediately. If the individual insists on brushing, then they should be told to use only a small amount of bicarbonate or desensitizing toothpaste to reduce any erosive impact. It may also be appropriate to prescribe artificial saliva pastilles, especially if medications are prescribed that dry the mouth.26
After disclosure and appropriate referral, it is important that dentists and other clinicians collaborate in the care of the patient,26 for example when considering medications to reduce any ongoing erosive impact on the teeth.
Conclusion
Dentists and dental care practitioners have an important role to play in the management of eating disorders. They may be able to provide an early diagnosis, as well as provide timely advice to reduce adverse impacts and refer to specialists for appropriate care and a multidisciplinary treatment approach.16 Thorough intra- and extra-oral patient examinations are necessary, together with effective and sensitive communication skills11 and an understanding that the dentist may be the first to suspect, broach the topic of, and diagnose, an eating disorder. If an eating disorder is suspected, then the dentist has a role in facilitating access to appropriate mental health services, as well as in providing oral healthcare advice and treatment.
