Oral Health Management and Coordination of Care

Management of clients with eating disorders requires assessment, intervention, dental and dental hygiene treatment, and collaboration with other health care providers. Assessment of eating disorders is typically not part of a standard medical history questionnaire. Although there may be a question related to changes in weight, this type of question alone will not suffice as a tool for determining suspected cases of eating disorders.

Additional information that can be solicited and assessed related to eating disorders includes signs of arrested growth; inability to gain (or lose) weight; constipation or diarrhea; susceptibility to fractures; delayed menarche or amenorrhea (in women); changes in eating habits; difficulty eating in social situations; depression; social withdrawal; excessive exercise; and concern about weight.1 General physical manifestations of eating disorders should be noted. A question that directly asks “Do you have an eating disorder?” can be used. Positive responses can be followed with additional questions that address the severity and duration of the eating disorder such as the type and frequency of purging behaviors (if applicable); factors precipitating bingeing or purging; medical interventions and current status of treatment; and periods of abstinence or control of behaviors.79

It is important to recognize that individuals with eating disorders may deny or be reluctant to disclose their eating problems. A thorough yet nonthreatening manner is needed to determine the extent of the eating
disorder, the honesty of the client, and the client’s willingness to receive help.

In the event an eating disorder is suspected or confirmed through responses to the medical history and/or oral examination findings, the dental hygienist and dentist may proceed with intervention. Intervention is a deliberate, planned approach to link the client with medical assistance such as a physician, psychiatrist, psychologist, eating disorder counselor, nurse, and/or registered dietician.62

Aguilera and Messick outline three steps in the intervention process.80 The first step is to assess the client and the problem, as adequate documentation is needed to exclude other possible diagnoses. The next step is to plan the intervention. The dentist and dental hygienist must decide who has the established rapport and trusting relationship to confront the client with their findings. The intervention should be conducted in an area that affords privacy to ensure confidentiality. The third step is to implement the plan. A nonjudgemental, direct approach is recommended. Concrete examples of oral manifestations of the disorder should be described to the client. For example, “I noticed that you have considerable erosion your teeth. Erosion such as this tends be the result of chronic exposure to acid and can be found in individuals who have bulimia nervosa. Do you have an eating disorder?”

Once the initial confrontation has been completed, the dental hygienist or dentist may find that the client is angry, denies the problem, or admits the problem. Individuals who admit to having an eating disorder require immediate referral for evaluation and treatment. It is helpful to have resources available that can be offered to the client so that timely intervention can occur. In addition, the dentist and dental hygienist should establish a liaison relationship with other health care professionals to coordinate oral health care with medical and psychiatric care.

In the December 2000 issue of Access, Austin and Crafton described their technique for confronting an individual with a suspected case of bulimia.81 Their technique was similar to that described by Aguilera and Messick.80 The diagnosis of bulimia was based on findings of erosion on the lingual surfaces of the maxillary anterior teeth and petechiae on the soft palate. Upon confronting the client with their findings, the client denied bulimic behavior, but did ask questions concerning a supposed friend who had the condition. The client was informed about bulimia, and the oral manifestations and systemic effects. She was advised that a referral to a professional who specializes
in the treatment of individuals with eating disorders was indicated for her “friend.”81

From a legal perspective, it is important to note that discussions concerning a suspected eating disorder in a client younger than 18 years of age should occur with the client and the parents. Clinical find-ings noted during the oral assessment, other recorded physical manifestations of an eating disorder, oral health treatment approaches, and referral for medical consultations should be presented to the parent or legal guardian.82

With respect to providing oral health care, information and instruction concerning the effects of purging and diet on oral health needs to be provided. Clients with eating disorders need to understand the effects of perimylolysis on their teeth, palate, and fingers. Individuals who induce vomiting should be advised to perform oral rinsing with 0.05% sodium fluoride, slightly alkaline mineral water, sodium bicarbonate, or magnesium hydroxide solution to neutralize the gastric acids following each vomiting episode.63,83,84 Tooth brushing after vomiting can be performed once the gastric acids have been neutralized. Those who are taking medications and experiencing xerostomia should be counseled to use artificial saliva preparations or oral lubricants. A high-carbohydrate diet and its role in caries formation should be discussed with the client. In the case of individuals with anorexia, the physician may prescribe a high-carbohydrate diet. Substitutes for foods with high-sugar content or high-acid contents, such as cheese, pretzels, crackers, and protein foods, can be suggested.

In terms of oral health treatment, periodic examinations, prophylaxis, and fluoride applications are recommended to prevent further deterioration of the enamel. In cases of extensive tooth erosion and dental caries, at-home applications of a sodium fluoride gel or stannous fluoride gel in custom trays are warranted to promote remineralization of tooth enamel. Study casts should be constructed to determine whether or not the tooth erosion has progressed or stabilized.

Restorative dental care is indicated for individuals presenting with tooth erosion and dental caries. In severe cases of erosion where the tooth pulp is exposed, the client should be referred to an endodontist.

The timing of delivering restorative care remains an issue. In general, it is recommended that palliative dental care be provided initially. Once the client has received counseling and is making progress in controlling the eating disorder, further oral health treatment can be rendered. Clients who cease bingeing and purging practices are ready for definitive restorative dental treatment.82 Discussion of the timing of oral health treatment with other members of the eating disorder health care team is useful. In some cases, providing dental restorative care serves as a source of motivation for the client to continue treatment and assists with building selfesteem. In other cases, withholding such treatment may be necessary, as the client may relapse and require further psychological or medical intervention.

It is important for the dentist and dental hygienist to be prepared to manage a medical emergency when providing oral health care to clients with eating disorders. These individuals are at risk for hypoglycemic syncope. Clinical manifestations of hypoglycemia include heart palpitations, sweating, confusion, irritability, headache, seizure, and unconsciousness. Sources of carbohydrates should be available in the dental office emergency kit. To avoid the chance of a hypoglycemic episode, the client should be advised to eat a light meal or snack prior to oral health care appointment.