Eating Disorders; Medical and Dental Considerations (PDF)

Eating Disorders: Medical and Dental Considerations Barbara J. Steinberg DDS Clinical Professor of Surgery Drexel University College of Medicine  Barbara J. Steinberg D.D.S. Clinical Professor of Surgery Drexel University College of Medicine  SCOFF QUESTIONNAIRE The SCOFF Questions* 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 Over 14 pounds in a 3-month period? Do you believe yourself to be Fat when others say you are too thin? Would you say that Food dominates your life? *One point for every “yes”; a score of 2 or more indicates a likely case of anorexia nervosa or bulimia nervosa. Reproduced from Obstetrics and Gynecology, Vol. 114, No. 6, December 2009; 1353-1367. Anderson AE, Ryan GL, Eating Disorders in the Obstetric and Gynecologic Patient Population. Barbara J. Steinberg, DDS Clinical Professor of Surgery Drexel University College of Medicine  156 The Journal of Dental Hygiene Vol. 88 • No. 3 • June 2014 Eating disorders are syndromes characterized by significant distur- bances in a person’s eating behavior, such as extreme over- or under-eat- ing, accompanied by intense focus or distress related to food consump- tion, body shape or weight.1 Eating disorders are both serious and po- tentially dangerous and are associ- ated with medical and psychological complications that give eating disor- ders a higher mortality rate than any other psychi- atric disorder.1 Morbidity and mortality rates may be even higher than officially reported because these patients often deny or hide the extent of their fasting, binge-eating and purging behaviors. Early detection and treatment are critical, and oral health care professionals are in an ideal position to help identify these disorders, which primarily affect women. Classification Originally conceptualized as discrete illnesses, eating disorders are now viewed as falling along a continuum between anorexia nervosa, bulimia nervosa and eating disorders not otherwise speci- fied. There can be crossover behaviors among all of these disorders.2 Anorexia nervosa is defined by the American Psychiatric Association’s Diagnostic and Statistical Manual on Mental Disorders, 4th edition (DSM-IV) as a refusal to maintain body weight at or above 85% of the normal weight for a particular age and height, accompanied by an intense fear of gain- ing weight, an undue emphasis on body shape or weight and amenorrhea for 3 consecutive months.2 Anorexia nervosa is further subdivided into re- stricting and purging subtypes.2 Patients with the restricting type will severely limit food intake and often over-exercise, whereas patients with binge- purge type will engage in purging behavior after eating in addition to food restricting.2 Bulimia nervosa is defined in DSM-IV as episodes of binge eating that recur at least twice weekly for Medical and Dental Implications of Eating Disorders Barbara J Steinberg, DDS Short Report Introduction 3 months or longer.2 The bulimic presents with the same undue emphasis on body weight and shape as seen in the anorexic, but weight loss may not be as remarkable or even noticeable as with anorex- ia.3 There are 2 subtypes of bulimia: purging and non-purging bulimia. In the purging type, binges are followed by inappropriate compensatory be- havior to avoid weight gain, such as self-induced vomiting or misuse of laxatives, diuretics or en- emas. In the non-purging type, the inappropriate compensatory behaviors typically include intermit- tent fasting and excessive exercise, but not purg- ing or misuse of laxatives, diuretics and enermas.2 The third DSM-IV category is eating disorder not otherwise specified. This includes all eating disor- ders that do not meet the strict criteria for either anorexia or bulimia and accounts for about 50% of eating disorders overall.2 For example, binge eat- ers fall into this category, but unlike patients with bulimia, they do not undertake the compensatory behaviors to avoid weight gain.4 Epidemiology Eating disorders occur primarily in women, who comprise 90% of patients affected. For anorexia nervosa, the lifetime prevalence is 0.5 to 1.5%, and the male-to-female ratio is 1:10. For bulimia nervosa, lifetime prevalence is 1 to 4.4%, with a male-to-female ratio of 1:20.1 Some experts es- timate that 16 to 25% of college students have symptoms of an eating disorder.1 Etiology Eating disorders arise from a complex combina- Abstract This manuscript was part of the proceedings from the confer- ence Advances in Practice, hosted by the National Center for Dental Hygiene Research & Practice, held in Phoenix, Arizona, on June 12, 2012. Keywords: Anorexia Nervosa, Bulemia Nervosa, eating dis- orders This study supports the NDHRA priority area, Clinical Dental Hygiene Care: Investigate the links between oral and sys- temic health.  Vol. 88 • No. 3 • June 2014 The Journal of Dental Hygiene 157 tion of genetic, biologic, psychological, family and cultural factors. Some researchers suggest that a cultural value on thinness accounts for the growing incidence of eating disorders in the U.S. and other Westernized countries.4 Likewise, the media’s on- going depiction of digitally altered or otherwise un- realistic female bodies may also play a role. Activi- ties that reward thinness or promote a particular weight classification, such as ballet dancing, mod- eling, gymnastics and wrestling, can also predis- pose someone to develop an eating disorder.5 Per- sonality traits, such as low self-esteem, difficulty expressing negative emotions, difficulty resolving conflict and being a perfectionist, are also contrib- uting factors.6 Some individuals may be genetically predis- posed to developing eating disorders. Family stud- ies show that first-degree relatives of patients with eating disorders have a 10–times greater lifetime risk of developing an eating disorder than do rela- tives of unaffected individuals.7 Systemic and Psychosocial Manifestations Eating disorders negatively affect every system in the human body. Some medical complications are manifested soon after the onset of an eat- ing disorder, whereas others smolder and emerge years later. Malnutrition is the primary cause of most medical complications seen in patients with anorexia, and purging leads to most medical com- plications seen in patients with bulimia. Systemic, physical and psychosocial manifestations that may be associated with eating disorders are located in Tables I, II.8 Underscoring the seriousness of eating disor- ders is the fact that women with anorexia nervosa have approximately a 50–times higher suicide rate than do similar-age women in the general popula- tion.1 Prognosis is better for patients with anorexia nervosa than with bulimia nervosa. Approximately 50% of patients with anorexia nervosa will achieve a normal weight with treatment. Patients with bu- limia nervosa have a higher rate of severe psy- chological disturbances and medical complications, and relapse is common after treatment.3 Oral Manifestations Dentition: The most extensive oral problems seen in patients with eating disorders are caused by self- induced vomiting.9 Perimylolysis, a smooth erosion of the tooth enamel, is common and manifests as a loss of enamel and eventually dentin on the lingual surfaces of the teeth caused by the chemical and mechanical effects of chronic regurgitation of low- • Abdominal pain • Bradycardia • Carotenosis • Constipation • Decreased metabolic rate • Dehydration • Dry, scaly skin • Dysphagia • Dysrhythmias • Esophagitis • Gastroesophageal reflux disease • Hypotension • Malnutrition • Osteopenia/osteoporosis • Russell’s sign (callus on knuckles from self- induced vomiting) • Sore throat Table I: Systemic and physical manifesta- tions of eating disorders8 • Anxiety • Depression • Obsessive compulsive disorder • Personality disorders • Physical abuse • Sexual abuse • Social phobias • Substance abuse Table II: Psychosocial manifestations of eating disorders8 pH gastric contents and movements of the tongue. Initially, this erosion can be observed on the palatal surfaces of the maxillary anterior teeth and has a smooth, glassy appearance. There are few, if any, stains or lines in the teeth, and when the posterior teeth are affected, there is often a loss of occlusal anatomy. Perimylolysis is usually clinically observ- able after the patient has been binge eating and purging for at least 2 years.9,10 There appears to be a relationship between the extent of tooth erosion and the frequency and degree of regurgitation, as well as with oral hygiene habits.9,10 The patient may complain of severe thermal sensitivity, or the mar- gins of restorations on posterior teeth may appear higher than adjacent tooth structures. There may be occlusal changes, such as an anterior open bite and loss of vertical dimension of occlusion caused by loss of occlusal and incisal tooth structure.9,11 Salivary Glands: Enlargement of the parot- id glands and occasionally of the sublingual and submandibular glands are frequent oral manifes- tations of the binge-purge cycle in patients with eating disorders. The incidence of unilateral or bi- lateral parotid swelling has been estimated at 10  158 The Journal of Dental Hygiene Vol. 88 • No. 3 • June 2014 to 50%.9,10 The occurrence and extent of parotid swelling usually follows a binge-purging episode by several days.11 Parotid swelling is soft to pal- pation and generally painless. In the early stages of the disorder, the enlargement is often intermit- tent, appearing and disappearing for a time before it becomes persistent. At that point, the cosmetic deformity tends to impart a widened, squarish ap- pearance to the mandible, compelling the patient to seek treatment. Possible spontaneous regres- sion of gland enlargement may occur with cessa- tion of purging.11 The precise etiology of salivary gland swelling has not been determined, but most researchers associate it with recurrent vomiting. Mechanisms may be cholinergic stimulation of the glands during vomiting or autonomic stimulation of the glands by activation of the taste buds.9,12 In some patients who binge and purge, there may be reduced unstimulated salivary flow. Flow may also be reduced by overuse of laxatives and diuretics. As such, xerostomia may occur in bulimic patients due to reduced salivary flow and/or from chronic dehydration from fasting and vomiting.9,11 Xerostomia combined with poor oral hygiene can increase risk for periodontal disease.3 Periodontium: Poor oral hygiene is more com- mon in anorexic than bulimic patients.11 As such, higher plaque indices and gingivitis may be more common as well. Some investigators have ob- served that xerostomia and nutritional deficiencies may cause generalized gingival erythema.11 Oral Mucosa: The oral mucous membranes and the pharynx may also be traumatized by binging and purging, due to the rapid ingestion of large amounts of food and by the force of regurgitation. The soft palate may be injured by objects used to induce vomiting, such as fingers, combs and pens. Dryness, erythema and angular cheilitis have also been reported.11 Dental Management If the oral health care professional suspects that a patient may have an eating disorder, a general screening question regarding any difficulty with eating or maintaining weight is recommended. This may lead to more direct questions and conversa- tion, especially if there is a noticeable dental in- volvement. Oral manifestations should be brought to the patient’s attention in a non-confrontational manner. The patient may or may not admit to hav- ing an eating disorder on initial questioning. The oral health care professional can persevere gen- tly during initial and subsequent appointments to open communication about the problem and make appropriate referrals when indicated. It is impor- tant to point out the serious medical complications that can occur with eating disorders and to men- tion that these may be avoided with proper medical and psychological therapy.3 Rigorous hygiene and home care are recom- mended to prevent further destruction of tooth structure.11 As previously reported, such measures should include the following:9,11 • Regular professional dental care • In-office topical fluoride application to prevent further erosion and reduce dentin hypersensi- tivity • Daily home application of 1% sodium fluoride gel, either applied in custom trays or with a toothbrush, to promote remineralization of enamel, or daily application of 5,000 ppm pre- scription fluoride dental paste • Use of artificial saliva for patients with severe xerostomia • Rinsing with water immediately after vomiting and followed, if possible, by a 0.05% sodium fluoride rinse to neutralize acids and protect tooth surfaces (patients should be discouraged from toothbrushing right after vomiting, as the abrasive action may accelerate enamel erosion) Regarding definitive dental treatment, most clini- cal authorities urge delaying complex restorative or prosthodontic treatments until the patient is adequately stabilized psychologically.11 The excep- tions may include palliation of pain and temporary but non-traumatic cosmetic procedures. The ratio- nale for this recommendation is that an acceptable prognosis for more complex dental treatment de- pends on cessation of the binge-purge habit.11 Members of the dental team play critical roles for identifying undiagnosed eating disorders. In fact, because of the visibility of oro-facial mani- festations, oral health care professionals may be the first to encounter such patients and to play the important role of making appropriate referrals for further diagnostic work-up and treatment. Effec- tive treatment requires a multi-disciplinary team of health professionals to provide medical/dental, psychological and nutritional support. It is impor- tant to keep in mind that eating disorders are silent killers that should not be taken lightly or ignored. Patients with suspected eating disorders should be confronted gently about suspected disorders, in- formed of potential complications, and encouraged to seek medical and psychological help. Consider- ing that eating disorders have the highest mortal-  Vol. 88 • No. 3 • June 2014 The Journal of Dental Hygiene 159 ity of all psychiatric disorders, early detection and intervention are vital.1 Barbara J. Steinberg received her DDS from the University of Maryland School of Dentistry and completed a residency at the Medical College of Pennsylvania. She is Clinical Professor of Surgery at Drexel University College of Medicine, as well as Adjunct Associate Professor of Oral Medicine at the University of Pennsylvania School of Dental Medi- cine. She is a Diplomate of the American Board of Oral Medicine. 1. Zerbe KJ, Rosenberg J. Clinical updates in women’s health care: eating disorders, Vol VII. Washington, DC: American College of Obstetri- cians and Gynecologists; 2008. 1-30. 2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric As- sociation; 2000. 539-550, 583-594. 3. Little JW. Eating disorders: dental implications. Oral Surg Oral Med Oral Pathol Oral Radiol En- dod. 2002;93(2):138-143. 4. Clouse AL. Eating disorders. In: Clouse AL, Sher- if K. Women’s health in clinical practice. Totowa, NJ: Humana Press Inc; 2008. 296-298. 5. Mehler PS. Diagnosis and care of patients with anorexia nervosa in primary care settings. Ann Intern Med. 2001;134(11):1048-1059. 6. Bulik CM, Tozzi F, Anderson C, et al. The relation between eating disorders and components of per- fectionism. Am J Psychiatry. 2003;160(2):366- 368. 7. Bulik CM. Exploring the gene-environment nex- us in eating disorders. J Psychiatry Neurosci. 2005;30(5):335-339. 8. Hague AL. Eating disorders: screening in the den- tal office. J Am Dent Assoc. 2010;141(6):675- 678. 9. Steinberg BJ, Minsk L, Gluch JI, Giorgio SK. Women’s oral health issues. In: Clouse AL, Sher- if K. Women’s health in clinical practice. Totowa, NJ:Humana Press Inc; 2008. 288-289. 10. Brown S, Bonifazi DZ. An overview of anorexia and bulimia nervosa, and the impact of eat- ing disorders on the oral cavity. Compendium. 1993;14(12):1594-1608. 11. American Dental Association Council on Access, Prevention and Interprofessional Relations. Women’s oral health issues. Chicago: American Dental Association; 2006. 11-14. 12. Mandel L, Kaynar A. Bulimia and parotid swell- ing: a review and case report. J Oral Maxillofac Surg. 1992;50(10):1122-1125. References