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Dental professionals can be the first line of defense in eating disorder diagnosis

June 17, 2010
Dentists and dental hygienists may see signs of eating disorders exhibited during routine visits, but without an arsenal of information and resources, they may not know the best way to direct patients to professional help — or if they should intervene at all. By understanding the etiologies of eating disorders, recognizing the mouth warning signs, and intervening when appropriate, dental professionals can help millions of Americans with these deadly diseases start down the road to recovery.
By Emmett R. Bishop Jr., MD, CEDS© iStockphoto®
Dentists can be the ‘first line of defense’Eating disorders such as anorexia nervosa and bulimia nervosa can have irreversible negative effects on an individual’s body and especially on his or her teeth, gums, or mouth. In fact, the initial indicators of an eating disorder are often evident in the mouth. Dentists, dental hygienists, orthodontists, and oral surgeons can be the first line of defense when it comes to identifying disordered eating warning signs and symptoms. Tooth decay, gum deterioration, and halitosis — among other symptoms — are potential red flags or “mouth warning signs” that can be apparent in as little as six months after disordered eating behaviors begin.Dentists and dental hygienists may see signs of anorexia or bulimia exhibited during a routine visit or checkup. However, without an arsenal of information and resources, they may not know the best way to direct their patients to professional help — or if they should intervene at all.By understanding the etiologies of eating disorders, recognizing the mouth warning signs, and intervening when appropriate, dental professionals can help the millions of Americans with these deadly diseases start down the road to recovery. Eating disorders 101More than 10 million women and one million men in the United States have anorexia nervosa or bulimia nervosa. Millions more struggle with binge eating disorder and EDNOS (eating disorder not otherwise specified). These potentially life-threatening diseases are biologically based, have a genetic link, and are as inheritable as schizophrenia or bipolar disorder. Eating disorders are the deadliest mental illness in the United States, and they can have detrimental effects both inside and outside the body.Anorexia nervosa, whether it is restrictive anorexia or binge/purge anorexia, is more common in the United States than Alzheimer’s disease1 and typically appears in early to mid-adolescence. Individuals with restrictive anorexia limit their food and caloric intake, often drastically, in order to reduce weight. Those with binge/purge anorexia both restrict and engage in binge/purge cycles, similar to individuals with bulimia nervosa.Bulimia nervosa is characterized by a cycle of binging and compensatory behaviors such as self-induced vomiting or laxative use. Individuals dealing with depression or changes in social environments may exhibit signs of bulimia. The binge/purge behaviors of bulimia are often the most revealing in an individual’s teeth, gums, and mouth in general. Binge eating disorder is a provisional diagnosis in the eating disorder field. It is a type of eating disorder typically associated with recurrent binge eating without the regular use of compensatory behaviors to counter the binges.EDNOS, or eating disorder not otherwise specified, refers to abnormal eating patterns without all the symptoms associated with the diagnoses of anorexia, bulimia, or binge eating disorder. Although an individual with EDNOS may purge after eating, he or she does so with less frequency than an individual with bulimia.The ‘mouth warning signs’Bulimia nervosa and the disordered eating behaviors that accompany the disease can lead to tooth and enamel decay, gum deterioration, swelling in the cheeks and jaw area, and halitosis. Anorexic behaviors can contribute to mouth warning signs as well. When anorexia leads to calorie restriction, the body will de-prioritize tooth and oral maintenance as it attempts to salvage protein, vitamins, and other nutrients to keep major body functions running. A routine dental checkup can reveal oral signs of these diseases to a dental professional. Here are some of the major warning signs:1. Tooth decayDecay of teeth and enamel is most frequently seen due to increased levels of stomach acid in the mouth from purging behaviors. Furthermore, individuals engaging in the calorie restriction of anorexia will often lean toward low-calorie, fizzy drinks or sports energy drinks to minimize overall caloric intake. These beverages are highly acidic and will eat away at enamel over time. This can also lead to an increase in the susceptibility to and number of cavities when teeth no longer have their protective enamel covering.2. Tooth sensitivityWhen an individual begins to experience erosion of tooth enamel, the sensitivity of teeth can increase drastically. Tooth sensitivity can also be seen in individuals who do not have eating disorders. Although it is not a telltale sign of an eating disorder, it can certainly be an oral complication of those diseases. The same purging or bulimic behaviors that cause tooth decay and enamel erosion also contribute to gum deterioration.3. SwellingBulimic behaviors such as repetitive purging can lead to swelling in the cheeks and jaw area. A related warning sign — though not occurring in the mouth — is the appearance of sores on the back of hands and knuckles from frequent purging.4. Halitosis and tooth discolorationIncreased stomach acid and bile in the mouth creates the perfect environment for halitosis and tooth discoloration to occur. Because of the intense nature of bulimia, no amount of teeth brushing and mouthwash can relieve the halitosis seen in eating disorder patients.Often individuals struggling with disordered eating behaviors will attribute poor dental health to acid reflux or a recent change in diet leading to an increase in consumption of more acidic liquids. What to do if you suspect your patient has an eating disorderEating disorders are biologically based mental illnesses that require a refined knowledge base to help a patient experience a lasting recovery. Intervention by loved ones, friends, and medical and dental professionals can spur someone to seek eating disorder treatment. Dental professionals can often easily recognize an issue or the possible warning signs associated with eating disorders, but addressing the issue with a patient can be difficult. As a dentist, if you believe a patient may be exhibiting disordered eating behaviors, you can approach the issue in a careful, thoughtful manner that does not place blame, but rather illustrates concern for the patient’s overall well-being. It is important to phrase the question in a way that the patient understands exactly what you are asking and does not include labels such as “bulimic” or “anorexic.” These labels can cause a patient to become more defensive about the issue. The question should be, “Do you make yourself throw up?” not “Do you have an eating disorder?” It is important to gauge the patient’s reaction when a sensitive topic such as this one is addressed. If the individual is defensive and denies possible bulimic or anorexic behaviors, referral to his or her primary care doctor will likely be the most beneficial course of action, as your patient may feel more comfortable discussing medical and psychiatric issues with a primary care physician. Some individuals may understand your concern. If this is the case, it is best to refer the patient directly to an eating disorder treatment facility. Furthermore, if your patient seems comfortable with the discussion, use it as an opportunity to discuss the possible — and sometimes irreversible — dental and oral complications of eating disorder behaviors. If the patient is a minor, it may be critical to express your concern to his or her parents as well. Though it may be ideal to ask a minor’s permission first, discussing your concerns with his or her parents may ultimately be in the patient’s best interest.A variety of treatment centers across the United States can offer treatment for anorexia, bulimia, binge eating disorder, and EDNOS. It is important that an individual dealing with these diseases find a treatment center that most appropriately addresses his or her individual needs. Eating Recovery Center, a treatment center I co-founded in Denver, Colo., is a licensed and Joint Commission accredited behavioral hospital treating eating disorders at any severity. We can be valuable partners as you help your patients seek treatment.
Emmett R. Bishop Jr., MD, CEDS, is the founding partner and director of research and outpatient services of Eating Recovery Center. He has more than 30 years of experience in the treatment of eating disorders. Dr. Bishop designed the multilevel Clarke Center Eating Disorder Program and has completed systematic research in the field. He served as the past president and current board member for the International Association of Eating Disorders Professionals. Dr. Bishop is also an Approved IAEDP Supervisor and sits on the editorial board of Eating Disorders: The Journal of Treatment and Prevention. Additionally, he is a fellow of the Academy for Eating Disorders.For more information about Eating Recovery Center, call (877) 218-1344, e-mail [email protected], or confidentially chat live on the Web site at