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Demmler JC, Brophy ST, Marchant A Shining the light on eating disorders, incidence, prognosis and profiling of patients in primary and secondary care: national data linkage study. Br J Psychiatry. 2020; 216:105-112 https://doi.org/10.1192/bjp.2019.153
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Eating Disorders and Orthodontics Amardeep Singh Dhadwal Ben Marnell Dental Update 2024 15:3, 707-709.
Authors
Amardeep SinghDhadwal
Final Year BDS Undergraduate Student, The Institute of Dentistry, Barts and the London School of Medicine and Dentistry, Queen Mary University, London, E1 2AT, UK
In modern-day practice, there is an expanding population of patients with suspected or confirmed eating disorders. Increased awareness of the presenting features and manifestations of eating disorders is required for recognition of this situation and appropriate management. This article provides an overview of features of common eating disorders that may present in practice. It will draw attention to potential difficulties when orthodontic treatment is required and will make recommendations on how to judiciously manage potential problems.
CPD/Clinical Relevance: This article outlines issues of importance for the orthodontic team when encountering patients with known or suspected eating disorders and provides guidance in the appropriate management.
Article
Eating disorders involve abnormal eating behaviours that are not part of another health condition, and not developmentally appropriate or culturally sanctioned.1 It is estimated that there are 1.25 million people in the UK with an eating disorder.2 The aetiology is thought to be multifactorial and attributed to a combination of genetic, psychosocial, biological and developmental determinants.3 Multiple similarities in the manifestations and risk factors among eating disorders, however, evoke difficulties in separating them based on their individual underlying features.4 Eating disorders adversely affect quality of life, and with a high morbidity, they have the highest mortality of all mental health disorders.5 Affected patients are at a greater risk of premature death and suicide.6
The detection of eating disorders increases with the onset of adolescence: a period in which many patients will embark upon orthodontic treatment. Orthodontists are in a unique position among medical professionals, because treatment occurs over a prolonged period and with regular appointments. Orthodontists usually see these patients every 6–8 weeks, and may be the only healthcare professional to encounter these often seemingly fit patients.7 It is important for orthodontists to be able to recognize eating disorders in their patients and refer them appropriately. It should not be assumed that patients only experience an eating disorder during adolescence. Their manifestations and signs of body image concerns, appearance ideals and dietary restraint could be encountered at any age and can continue throughout life. This was emphasized by a study of 5-year-old girls in which over one-third of them demonstrated weight-focused dietary restraint tendencies in relation to body image.8
This overview highlights the most prevalent eating disorders, their manifestations, management and relevance to orthodontic practice. Table 1 summarizes the most common eating disorders: anorexia nervosa,9,10 bulimia nervosa,11,12 and binge-eating disorder.12,13Table 2 outlines other relevant, but less common eating disorders: diabulimia,14,15 PICA,16 and night-eating syndrome.17,18 Oral signs of eating disorders will develop within approximately 6 months of onset.19 They can be divided into mucosal, dental and salivary manifestations.
Eating disorder
Features
Anorexia nervosa
Unhealthily low body weight for someone of their age, height and development, not attributable to other determinants, such as a medical condition or food unavailability.
For adults, BMI of less than 18.5 kg/m2. For children and adolescents, the BMI-for-age is under the fifth percentile
Body image obsession with persistent self-evaluation to maintain suboptimal weight
Those affected may inaccurately consider their weight to be excessive or normal, and obsessively fear and avoid further weight gain
Partake in behaviours that aim to restrict food intake: self-induced vomiting, laxative misuse (purging) and excessive exercise. Nutritional deficiency can subsequently occur
Age of peak incidence recently estimated to be 15 and 16 years for young women and men, respectively, with an increasing incidence rate in children aged 12 and under
Bulimia nervosa
Characterized by a combination of frequent and recurrent binge-eating episodes with inappropriate compensatory actions to avoid weight gain
Their weight is deemed ‘normal’ by definition because their BMI does not reach the diagnostic threshold for anorexia nervosa
Epidemiological data vary, but highlight how the peak age of diagnosis for bulimia is 15–19 years, with the incidence rate increasing beyond this age through the twenties
This reported older age at diagnosis could be attributed to the fact that individuals may not appear noticeably underweight thus the condition may remain undetected for a greater time period. Those affected may appear overweight as obesity is a common comorbidity in bulimic patients
Binge-eating disorder
Recurrent and frequent episodes of consuming excessive amounts of food in a short period of timeIndividuals feel a lack of control and compulsion to continue binge eating even if they do not feel hungry
It is often considered distressing for patients, causing them to feel ashamed, guilty or embarrassed during and after their binge-eating episodes
This condition does not involve compensatory behaviours and so affected patients are often overweight
Median age of onset is considered to be late teens to early twenties. There is a lack of national data, but a global estimated prevalence of 1.4% and some countries reporting a prevalence of up to 6.9%. This emphasizes its severity and place as a recognized public health problem alongside other eating disorders
Eating disorder
Features
Diabulimia
Diabulimia/ED-DMT1 (Eating disorder-diabetes mellitus type 1) typically refers to type 1 diabetic patients with an eating disorder
Individuals manipulate their insulin dose in an attempt to lose or control body weight. This may occur as a result of diabetic burnout or a preoccupation with weight loss and body image
Diabulimia can have life-threatening consequences, with one study noting insulin restriction in up to 30% of diabetic women
PICA
Regularly consuming non-food objects and materials, with insignificant nutritional value, such as hair, plastic or soil
Affected individuals are at a developmental age where they would be expected to distinguish between non-edible and edible substances. Iron-deficiency anaemia, pregnancy and malnutrition are recognized as common aetiological factors
It is the most common eating disorder in individuals with learning disabilities, affecting around 10–15% of these patients
Night-eating syndrome
Characterized by a delayed pattern of food intake where, after an evening meal or during the night, individuals have recurrent episodes of nocturnal eating to consume large calorie intake
Commonly associated with other psychiatric disorders including anxiety, depression and sleep disorders. It can be accompanied with a feeling of powerlessness and lack of control over eating patterns
Characteristic behaviours may have started through habits such as late night studying and persisted in adulthood. Patients therefore may not consider it to be a problem and be surprised at a diagnosis
Mucosal and soft tissue manifestations
Behaviours associated with eating disorders promote suboptimal dietary habits that can cause nutritional deficiencies. Poor nutrition can influence the integrity of the oral mucosa. Intra-orally, this can manifest as ulceration, glossitis and mucosal atrophy (Figure 1).20 Extra-orally, it can cause skin irritation and angular cheilitis at the labial commissures (Figure 2).21 Patients with nutritional deficiencies have an increased susceptibility to opportunistic infections including Candida (Figure 3). While poor periodontal health has been linked to nutritional deficiencies, particularly vitamin C due to its role in connective tissue formation and repair,22 there is insufficient evidence to suggest that eating disorders significantly contribute to periodontal disease and increased dental plaque formation.23
Figure 1. Recurrent oral ulceration affecting the lower labial mucosa. Clinical image courtesy of the Oral Medicine Department, Birmingham Dental Hospital.Figure 2. Angular cheilitis affecting the left labial commissure. Clinical image courtesy of the Oral Medicine Department, Birmingham Dental Hospital.Figure 3. Erythematous candidiasis of the dorsal surface of the tongue. Clinical image courtesy of the Oral Medicine Department, Birmingham Dental Hospital.
Traumatic ulceration of the palatal tissues and pharynx, as a result of frequent vomiting, may occur due to repeated gastric acid exposure. Such ulceration can vary from an aphthous-like ulcer to necrotizing sialometaplasia which, although benign in nature, is a differential diagnosis for oral squamous cell carcinoma owing to its similar appearance.24 This emphasizes the varied appearance of ulcers that can occur as a manifestation of eating disorders and the need for vigilance during clinical examination. The tissues may also be traumatized and erythematous as a result of contact with pens, fingers or hairbrushes used to encourage vomiting by bulimic patients. This can cause physical and psychological pain, deterring patients from eating. Extra-orally, patients who purge may present with bruises and teeth marks on their knuckles, or calluses on their hands and fingers from forcefully using their hands to induce vomiting.25
Salivary manifestations
Salivary gland hypertrophy is a common manifestation of eating disorders and purging behaviours. This typically involves asymptomatic unilateral or bilateral swelling of major salivary glands, particularly the parotid glands, and may be the only extra-oral sign exhibited by the patient.26 This can be recurrent and swelling size often correlates with purging.
To avoid weight gain, patients may perform behaviours such as persistent vomiting and medication misuse. This increases the likelihood of dehydration, reduced salivary flow rate and xerostomia. Additionally, patients with eating disorders show higher levels of other mental disorders and may be taking antidepressants that result in xerostomia.5 As well as contributing to halitosis, altered taste, burning sensations and increased caries susceptibility, xerostomia has a significant impact on oral health-related quality of life.27
Dental manifestations
Patients who binge-eat consume a high sugar intake through unhealthy snacks and fizzy drinks. Similarly, patients with anorexia and other eating disorders may opt for these easily accessible choices under the impression that they will suppress feelings of hunger and provide a good energy source.28 They may also suck citrus fruits to encourage appetite suppression. Excessive and frequent consumption of dietary sugars and acids increases susceptibility to extensive dental caries and tooth surface loss. This can subsequently manifest as erosive tooth wear and exposed dentine (Figure 4). If this is prolonged, it can resort in darker teeth, pulpal exposure and reduced clinical crown height.
Figure 4. Severe palatal erosion of the maxillary anterior teeth with enamel loss, exposed dentine and raised restorations. Clinical image courtesy of Dr Upen Patel.
Tooth wear can also be worsened and accelerated as a result of purging and vomiting. These behaviours force gastric acid to contact and erode tooth surfaces. Restorations may appear raised on clinical examination as a result of surrounding tooth tissue loss (Figure 4). Dental erosion is also commonly found on the palatal surfaces of anterior maxillary teeth (Figure 5). As a result of tooth surface loss or caries, patients may experience pulpitis and present with pain (with or without a causative stimulus), or noticeable dentine hypersensitivity arising from simple everyday tasks such as drinking water or tooth-brushing.
Figure 5. Generalized palatal wear with localized areas of exposed dentine on UR56. Clinical image courtesy of Dr Raheel Malik.
Orthodontic considerations and management
The literature highlights orthodontic treatment precipitating dietary restraint, and a change in dietary habits, in patients who were subsequently diagnosed with eating disorders.29,30 In some cases, patients reported orthodontic treatment as the main precipitant for their changes in behaviour and eating disorder. Orthodontic treatment can serve as a precipitant in a vulnerable person, where they may experience food getting stuck in their appliances, pain from an appliance or changes in dietary habits following instructions given, such as avoiding certain foods or sweets, which emphasizes the need for holistic monitoring of patients throughout treatment sessions.
DMFT scores for patients with eating disorders are often significantly higher than healthier patients.31 Patients with eating disorders may be non-compliant if they are worried that, during an examination or treatment, their clinician may detect their condition.32 There is no correlation between orthodontic abnormalities arising as a result of eating disorders.33 It has been well recognized, however, that body image is a significant factor for patients seeking orthodontic treatment, and it affects how they perceive themselves.34
The orthodontist must also be aware of the higher morbidity associated with patients with low body mass index and surgery. These patients need a full anaesthetic assessment prior to embarking on any surgical treatment, to ensure the benefits of surgery outweigh the risks.
Medical interventions
It is important to take a comprehensive history at each appointment. Any suspected conditions should be fully explored by appropriate medical personnel and identified, before any orthodontic treatment is undertaken. Individuals who are underweight due to an eating disorder have an increased susceptibility to bradycardia, hypotension and hypothermia, and indicators such as blood pressure, pulse rate and degree of underweight are used as risk indicators.
If an eating disorder is suspected, communication with patients and their families or carers should demonstrate compassion and empathy in discussing this sensitive topic without direct interrogation about the patient's weight. If an eating disorder is suspected, the patient should be referred to their general medical practitioner (GMP); however, confidentiality must be maintained, and consent should be requested to do this. Releasing information without permission can only be carried out in exceptional circumstances and appropriate guidance and advice should be sought prior to releasing information.35 The GMP can assess and coordinate care for patients with a suspected eating disorder where they can make a psychosocial and physical assessment. They may refer to secondary care for further input to ensure interventions can take place as soon as possible. Patient management should be in accordance with NICE guidelines.36 The dental team should be familiar with this guidance to understand the holistic impacts and care pathways available for patients with eating disorders. Key aspects of this care may involve therapy, nutritional counselling and behavioural interventions. Healthcare professionals have a duty to ensure that patients and their families are appropriately educated and signposted to organizations for support, and sources of information on the nature and risks of their disorder and its sequelae.
Dental interventions
Orthodontists will need to liaise with the patient's regular general dental practitioner (GDP) to raise concerns at the earliest sign. Any active orthodontic treatment may need to be stopped and the patient referred back to their GDP until the condition is stabilized. It is crucial to implement a personalized preventive plan to prevent further oral health deterioration while adopting a common risk factor approach when providing preventive advice. Education on the impact of dietary habits on general and oral health is essential, as well as the prescription of high-fluoride toothpaste, mouth rinse and topical fluoride varnish application at reduced recalls, to help manage and reduce caries risk.37 Areas of exposed dentine may require sealing or symptomatic relief with a desensitizing toothpaste. Patients with purging behaviours should be advised not to brush immediately following vomiting, but instead, to consider rinsing with fluoridated mouthwash and chewing sugar-free gum.28 For patients with dry mouth, oral lubricating gels, chewing sugar-free gum or being prescribed artificial saliva may relieve oral dryness. Individuals may experience chronic fatigue as a result of insufficient calorie intake, malnutrition, and depression.19 For such patients, shorter appointment times and treatment duration should be considered. Regular monitoring and reduced recall intervals are vital in ensuring that oral health is stable.
Conclusions
There is an expanding population of patients with suspected or confirmed eating disorders and so the likelihood of these patients being encountered in an orthodontic setting is increasing. There are several key practical considerations for an orthodontist to consider in managing these patients.
Given their unique position to treat patients regularly and over a prolonged period, the orthodontist may be the first healthcare professional to encounter seemingly fit patients with signs of eating disorders. They should handle these situations sensitively and refer such patients to their physician, while upholding principles of confidentiality and consent in most cases.
To maintain optimal oral health, an orthodontist will need to liaise with the patient's regular general dental practitioner (GDP) to raise concerns at the earliest sign. Any active orthodontic treatment may need to be stopped and the patient referred back to their GDP until the condition is stabilized.
Providing preventive oral healthcare, including dietary advice, a suitable fluoride regimen, advice on how to increase salivary flow and intra-oral pH (such as through chewing gum or rinsing the mouth with water or milk) can help prevent oral health deterioration.
Monitoring dietary habits is vital in assessing risk of dental disease, treatment suitability, and any eating habits or behaviours associated with eating disorders. Tailored dietary advice should be provided to all patients accordingly.
For patients in treatment, enquiring about compliance with orthodontic appliances and any subsequent dietary changes or oral pain can help to identify any precipitants for changes in habits and behaviours associated with eating disorders.
Taking a diet history and providing dietary advice should also be considered post-treatment, at any recall or debond appointments, as patients may continue with pathological eating patterns even after treatment has finished.
This article highlights the need to be aware of the presenting features, management and orthodontic treatment considerations to ensure appropriate patient recognition and judicious care provision.
