Patients with eating disorders: Challenges for the oral health professional

Originally published in the August/September 2013 issue of Dispatch

Eating disorders represent a serious, life threatening psychiatric illness affecting a disproportionate number of females. The lifetime prevalence is approximately 3%.

This illness usually arises during adolescence, a period of major life transitions.

Adolescence is a time for a search of individuality, purpose, and independence, when identification with peer groups becomes increasingly important. The result may be a selective rejection of beliefs and values that were established previously by family, peers and society in general.

Constant bombardment from the media with images of ultimate thinness has pushed dieting into the realm of socially acceptable behaviour. The etiology of eating disorders is, however, often more complex, involving an intricate interplay among biological, psychological and social issues. Research now suggests possible genetic links contributing to the development of eating disorders.

While food appears to be the central issue, in reality it is the characterization of food-related problems that become an outlet for the expression of a variety of more serious underlying psychosocial issues or disturbances. The result is a problematic coping strategy.

Common co-morbid psychiatric disorders can include depression, anxiety or personality disorders and substance abuse. While sociocultural factors instill a desire for thinness and beauty, they often simultaneously stigmatize obesity.

Dieting quickly becomes a measure of self-esteem giving the individual a sense of personal control that results in an ongoing obsession with weight loss, food and exercise. Such a change in focus perpetuates the illness with potentially severe consequences. The mind develops a distorted or even delusional thought process about body image, perceiving oneself as continually being too fat. Psychopathology quickly translates into a physiopathology defining a particular subtype of eating disorder.

The three main types of eating disorders include:

• Anorexia nervosa characterized by food restriction and being chronically underweight.
• Bulimia nervosa characterized by binge eating and inappropriate compensatory behaviours ultimately resulting in feelings of guilt and low self-esteem.
• Binge-eating characterized by compulsive overeating in which people consume huge amounts of food while feeling out of control and powerless to stop.

Not surprisingly the early detection of eating disorders is important, because of the potential psychological and somatic complications, and for the effects on oral health as well.

Dentistry can play a significant role in the diagnosis, support, and long-term management of those patients suffering from an eating disorder. However, as with any significant health issue, one of the greatest challenges for the dentist is to perceive that a medical problem, such as an eating disorder, represents a threat to a patient’s overall physical or oral health or both combined.

Without this perception or acknowledgement, there is far less engagement of secondary preventive behaviours that could lead to earlier identification, referral and treatment. As well, the opportunity for collaboration and integration of oral health care with mental health care services is lost.

Eating disorders continue to represent a serious and, often fatal, threat to an individual – a threat which can be prevented through earlier recognition and treatment.

Every dental practice will undoubtedly include patients dealing with a particular eating disorder. Many of these patients may appear healthy, despite struggling on the inside with this illness. Patients with eating disorders often become very secretive in their contacts with any health care professional because of the self-denial, shame and guilt associated with the illness.

That is why it is important for dentists and their staff to become more familiar and confident in recognizing the various oral signs and symptoms of eating disorders. At the same time, it is equally important to demonstrate empathy and support to your patient.

The best course of action is collaboration with a multidisciplinary health care team that is designed to provide early intervention and management of the unique physical and psychological needs of patients suffering from an eating disorder.

Sidebar

At the chairside

Oral signs and symptoms of eating disorders

• enamel erosion with increased thermal sensitivity
• increased caries rate
• gingivitis, periodontitis
• xerostomia, sialadenosis
• mucosal atrophy

Possible dentist-patient interview questions

• Your teeth are quite badly damaged. I am not totally certain why this has happened. But we do see these kinds of changes quite often in young men and women who drink a lot of diet drinks. Is this something you do on a regular basis?
• Sometimes the kind of changes that I see in your teeth show up when a young person is making herself/himself sick. Is this something you do?
• Do you ever eat in secret?

Clinical intervention strategies

• Interim preventive care: bicarbonate rinses, fluoride trays/rinse, dry mouth protocols, desensitization
• Definitive treatment (modified protocol): provisional restorations, desensitization
• Definitive treatment (normal protocol – purging behaviour has ceased): veneers, endodontics, orthodontic repositioning, full coverage restorations