As dental professionals, our job is to care for our patient’s teeth and manage their overall oral health. In doing so, however, sometimes we can uncover aspects of a patient’s systemic health that leave clues within the mouth, which otherwise may go undetected. Moreover, as orthodontists we have a unique opportunity to see a patient population composed largely of adolescents and young people, who generally are at a higher risk for one particularly detrimental condition, disordered eating.
Disordered eating encompasses a wide range of irregular eating behaviors that may or may not fit the diagnosis of a particular eating disorder. Two specific eating disorders, and likely the two most commonly encountered, Anorexia Nervosa (AN) and Bulimia Nervosa (BN), have oral implications that can be recognized by a dental professional, potentially even sooner than by one’s family or friends. With National Eating Disorders Awareness Month, along with National Children’s Dental Health Month, approaching in February, we wanted to discuss the relationship between eating disorders and oral health, and raise awareness for both.
Anorexia, characterized by extreme food restriction and a deficit in caloric intake, has serious consequences aside from weight loss. Lack of proper nutrition can lead to deficiencies in key vitamins such as calcium, iron, and B-vitamins, leading to several issues within the mouth. Lack of calcium and vitamin D can lead to tooth decay and gum disease, lack of iron can cause oral sores, and insufficient B-complex vitamins can cause canker sores, gingivitis, and bad breath. A concomitant problem to Anorexia, dehydration, can also increase the rate of tooth decay by exacerbating xerostomia (dry mouth) as the lack of salivary flow renders the oral environment unbuffered from acids in the mouth. The presence of these signs and symptoms, particularly in younger populations, can trigger dentists to take a closer look at a patient’s nutrition.
Bulimia, or the cycle of binging and purging, can also lead to side effects within the oral cavity. According to the National Eating Disorders Association (NEDA), 89% of people with Bulimia have signs that show up in the mouth (2002). When purging, stomach acid sits on the teeth and can erode the enamel, or outer protective covering, of our teeth, causing changes in color, shape, translucency, strength, and sensitivity. Most characteristically, erosion of enamel on the lingual, or tongue side, of the lower front teeth is often times an indicator of excessive purging and can warrant further questions from the dental professional and notification of parents or guardians about a potential problem. In addition to enamel erosion, purging can lead to scratches or sores inside the mouth, particularly on the soft palate (roof of the mouth), and painful enlargement of a patient’s salivary glands. Other warning signs of purging include, but are not limited to tooth decay, gum pain or bleeding gums, dry mouth, sore throat, inflammation of the esophagus, problems swallowing, cracked lips, issues with jaw alignment, and even degenerative arthritis of the TMJ (temporomandibular joint [jaw joint]) causing pain, headaches, and problems chewing, opening, or closing. While many affected by Bulimia choose to binge and purge in private to conceal their condition, dental professionals cause use the teeth, tissues, and other signs and symptoms to reveal potential cases of disordered eating.
Aside from the oral implications, eating disorders can cause metabolic and electrolyte imbalances, gastrointestinal concerns, gynecological and obstetric abnormalities, neurologic presentations, certain cardiac, endocrine, hematologic, psychiatric, and renal concerns, as well opportunistic infections. It is important to come to regularly scheduled dental appointments so that these signs and symptoms can be recognized early, and patients can get the help they need. Individuals with disordered eating should see a specialist in eating disorders to help manage their condition, which often requires a multidisciplinary approach of physicians, mental health professionals, and dental providers. Although an eating disorder as a whole needs to be managed and eliminated, while the process is still ongoing dental professionals have recommendations to help reduce the oral side effects. Some recommendations include rinsing with water after purging to reduce stomach acid within the mouth, waiting to brush for 1 hour after purging to avoid scrubbing acid deeper into the enamel, using rinses for dry mouth to help lubricate and buffer the mouth, and use of fluoride or remineralizing agents to help arrest tooth decay.
If you or a loved one have a suspected eating disorder or suffer from some aspect of disordered eating, there are an abundance of resources available to obtain help and take steps toward recovery. The National Eating Disorders Association (NEDA) has a helpline, shown here, for those who have questions or need help with an eating disorder. Visit their webpage for more information regarding disordered eating, the associated signs and symptoms, and ways to get help: nationaleatingdisorders.org
By Dr. Rachel Boschetti