CE Course 8

Eating Disorders

Credit: Continuing Education Hours: 2
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Table of Contents


Course Goals

The purpose of this continuing education course is to review the types, etiology, systemic and oral manifestations, and treatment of eating disorders. The role of the oral health professional in the assessment, prevention, treatment, and referral of clients with eating disorders will be addressed.


Learning Outcomes

Upon completion of this course, the participant will be able to:

  1. Identify the types of eating disorders.
  2. Describe the risk factors associated with eating disorders.
  3. Distinguish the clinical characteristics anorexia nervosa and bulimia.
  4. Identify the oral manifestations associated with eating disorders.
  5. Describe the physical complications of eating disorders.
  6. Discuss treatment options and the prognosis for clients with eating disorders.
  7. Appreciate the role of oral health professionals in addressing the needs of individuals with eating disorders.

Assessment Method: Post-test only


Abstract

Eating disorders are a serious concern in clients’ health and a challenge to oral health professionals. These illnesses, including anorexia nervosa, bulimia, binge eating, and pica, are characterized by serious disturbances in eating and effects on psychological health. Physiologic changes associated with eating disorders may be devastating and can lead to mortality.

Despite the serious consequences of eating disorders on physical and psychological health and well being, these disorders are often difficult to diagnose. Even when detected, ill clients may be averse to accepting treatment. Thus, oral health professionals must be aware of the signs of eating disorders, and be prepared to collaborate with other health care providers to treat them.

The purpose of this course is to review the medical and dental literature concerning eating disorder types, risk factors, systemic health consequences, oral manifestations, and treatment considerations. The role of oral health professionals as part of an interdisciplinary health team focused on addressing the needs of clients with eating disorders will be addressed.


Introduction

Eating disorders vary in type and presentation, and can affect approximately five million Americans each year.1
These illnesses typically occur in adolescent girls or young women. It is estimated that 3% of young women have an eating disorder and more than twice that number have clinical variants.2-4 Eating disorders are more prevalent in industrialized societies and occur in all socioeconomic classes and major ethnic groups in the United States.5-7
Because dental hygienists and dentists examine clients at frequent intervals and have established rapport with their clients, they are in a unique position to identify an eating disorder. Oral health professionals must have knowledge of the etiology, symptoms, and treatment options available to encourage individuals with an eating disorder to seek intervention. This course provides oral health professionals with information that will enable them to appreciate the complexities of eating disorders, recognize types of eating disorders, and integrate oral health care treatment for individuals who present with clinical manifestations.


Anorexia Nervosa

Anorexia nervosa is a psychiatric disorder characterized by abnormal eating behaviors that can result in significant weight loss and serious medical consequences. The term anorexia nervosa means loss of appetite for nervous reasons. Sir William Gull first described this disorder in 1868, and the French physician Lasegue named it.8,9 The essential features of this eating disorder have not changed since it was initially described.

Anorexia is defined as a disorder characterized by refusal to maintain body weight over a minimal normal weight for age and height, an intense fear of gaining weight, and distorted body image.10 Table I presents the diagnostic criteria for anorexia according to the Diagnostic and Statistical Manual for Mental Disorders, fourth edition (DSM-IVTR).11 Anorexia is also divided into two subtypes—restricting anorexia characterizes individuals who drastically limit their food intake, and purging anorexia describes individuals who engage in purging behaviors.

The use of the term anorexia for this eating disorder is a misnomer as there is no true appetite loss. While the individual with anorexia may claim to have appetite loss, they are starving. The pattern is to alternate food avoidance with overeating.

Anorexia affects 1 to 2% of the population and occurs most frequently among the adolescent age group. A bimodal pattern of onset exists occurring at the ages of 14 and 18 years.4 The female-to-male ratio of anorexia is 10:1, although approximately 15% of cases occur in men. This disorder is found predominantly in white, middle- and uppersocioeconomic classes. Groups considered to be at risk for anorexia include dancers, runners, skaters, models, actors, gymnasts, wrestlers, and college sorority members, for whom thinness is emphasized and highly valued.12-15

Anorexia is a disorder that affects all organ systems. Clinical manifestations and symptoms represent secondary effects from starvation and include changes in vital signs such as hypotension, bradycardia, and hypothermia. Dry skin, hypercarotenemia, lanugo (fine body hair), loss of muscle mass, and atrophy of the breasts may be noted. Dehydration and malnutrition may contribute to headaches, lethargy, dizziness, and syncope. Gastrointestinal signs of anorexia include intestinal dilation from constipation and diminished intestinal motility. Amenorrhea and osteopenia also are common findings in individuals with this eating disorder. Cardiovascular changes include a prolonged cardiac output (QT) interval found on electrocardiogram (ECG), and a decreased ventricular mass and mitral valve prolapse demonstrated also on an echocardiogram. Psychological manifestations of anorexia include difficulty concentrating and making decisions, depression, social withdrawal, and obsessiveness (particularly with food). Individuals with anorexia may refuse help, while maintaining that they are “fine” even in advanced stages of malnutrition.12,16 A summary of complications that can occur as a result of anorexia appears in Table II.

The etiology of anorexia is based on biologic, psychological, and social issues. Studies of families and
twins suggest there is a weak genetic component for the etiology of anorexia.17 The disorder is considered to be developmental more so than mental. Therefore, predisposing, precipitating, and perpetuating factors are more useful to consider than actual causes.

Factors considered to predispose an individual to anorexia include female gender, family history of eating disorders, perfectionist personality, difficulty communicating negative emotions, difficulty resolving conflict, and low self-esteem. Precipitating factors associated with anorexia focus on developmental changes, such as sexual development and menarche in persons aged 10 to 14 years, which leads to a spurt in weight gain; independence and autonomy struggles in individuals aged 15 to 16 years; and identity conflicts in individuals aged 17 to 18 as they transition from home to college or married life. Perpetuating factors are those that maintain the eating disorder. Examples of these include signs and symptoms of starvation and coping strategies engendered by the eating disorder.12,19-20

With respect to a physiologic etiology for anorexia, studies of serotonin and leptin in individuals with anorexia nervosa have yet to clarify if changes in these chemicals represents a cause or a consequence of the disorder. Increases in the neurotransmitter serotonin lead to reductions in food intake, while decreases in brain serotonin function are associated with depression and suicide attempts. Levels of serotonin are low in underweight individuals with anorexia, but will rise to normal levels in individuals who have recovered. A disturbance in serotonergic function may be a risk factor for the development of anorexia. Conversely, high levels of serotonin can be associated with perfectionism and rigidity, characteristics that are often seen in individuals with anorexia before the illness develops.21

Leptin is a hormone secreted by fat cells that plays a role in the regulation of body fat stores. Underweight individuals with anorexia have low serum levels of leptin, which increases with weight gain. Alterations in leptin regulation may play a role in the persistence of anorexia contributing to difficulties in attaining and maintaining normal weight.21

Brown and Bonifazi contend that sociocultural factors that instill a desire for thinness and beauty in women while stigmatizing obesity may be a causal factor in anorexia and other eating disorders. They note that the media provides an overwhelming amount of information on dieting, and the images of the beauty ideal have moved toward an increasingly thin image.10 However, the average woman has experienced increases in weight. This disparity between actual weight and socially acceptable weight ideals creates a vulnerability to body dissatisfaction, loss of control, and self-hatred.

Individuals with anorexia usually present with dramatic abnormal physical findings allowing a diagnosis to be more easily rendered even when the individual is denying any problems. However, anorexia is a clinical diagnosis, and no specific diagnostic tests exist to determine the disorder.

Laboratory studies can be performed as part of a diagnostic workup for anorexia. These included a complete blood count with erythrocyte sedimentation rate (ESR), urinalysis, and blood chemistries. Findings of these studies may reveal hyponatremia, which reflects excess water intake or the inappropriate secretion of antidiuretic hormone (ADH); hypoglycemia; an elevated BUN signaling dehydration; elevations in cholesterol in cases of starvation; leukopenia; and thrombocytopenia. The hemoglobin and ESR are typically normal. If these results are elevated, further investigation of an organic etiology are warranted.12,22,23
Since cardiovascular complications account for the majority of the morbidity and mortality associated with anorexia, an electrocardiogram and echocardiogram are warranted. A prolonged QT interval indicates potentially harmful dysrhythmias may occur.

Bone loss is a serious problem that is associated with amenorrhea and malnutrition, and should be assessed by bone densitometry. Fifty percent of women with anorexia have bone density measurements that are more than two standard deviations below normal.24,25 Bone loss may occur in young women after just six months of the illness.24,26 It can persist even after the recovery of weight. Symptomatic compression fractures and kyphosis are longterm risk factors.27,28

Kriepe et al. developed staging criteria for anorexia.29 These criteria appear in Table III.


Bulimia Nervosa

The term bulimia is derived from the Greek word for ox hunger and depicts the extreme nature of binge eating. Cases of bulimia nervosa, which is characterized by binge eating and purging, were not reported until the 1970s.30 Purging behavior may include induced vomiting by ipecac or other means, or abuse of laxatives, enemas, diuretics, caffeine, or other stimulants.1 However, it is more difficult to recognize than anorexia because individuals with bulimia nervosa exhibit no signs of illness and most are of normal weight. Studen-Pavlovich and Elliott relate that “normal weight is the most distinguishing characteristic in differentiating anorexia nervosa from bulimia nervosa.”31

According to the Diagnostic and Statistical Manual of Mental Disorders, binge eating and other behaviors must occur at least twice a week for a period of three months to qualify for the diagnosis of bulimia. Table I presents the diagnostic criteria for bulimia.

The prevalence of bulimia among women is 1 to 3% while the rate of occurrence among men is 0.1%. The risk for bulimia is associated with age, gender, and race. Most cases occur in late adolescence or early adult years with the median age of onset at 18 years. Cases of bulimia typically occur in industrialized countries where food is plentiful and a preoccupation with thinness in women is apparent.31,32

The binge and purge cycle characteristic of bulimia can affect multiple organ systems resulting in a variety of medical complications. Overeating associated with binge episodes can stretch the stomach or delay gastric emptying. Purging can induce esophagitis, gastroesophageal reflux disease, or esophageal rupturing.32,33 Pancreatitis and renal function impairment may occur. Protein malnutrition, dehydration, and electrolyte imbalances can occur leading to hypokalemia and hypochloremia, muscle cramping, weakness, dizziness, excessive thirst, parasthesia, and syncope.34 Bruises, calluses, scarring, and abrasions of the fingers may be present, reflecting excessive induced vomiting behaviors. In severe cases, cardiovascular abnormalities can result in arrhythmias, arrest, cardiac rupture, or pneumomediastinum.32

The etiology of bulimia has been associated with genetic, physiological, psychological, and environmental
factors. Several hypotheses exist concerning a physiologic explanation for bulimia, suggesting specific chemical abnormalities in the body. One hypothesis involves abnormalities of serotonergic function. Serotonin is involved in the development of satiety. It is believed to increase postprandial satiety rather than directly decreasing appetite. Disturbances in serotonergic function or low levels of serotonin may be responsible for blunting the sensation of satiety and prolonging periods of food ingestion. Another possible pathophysiology involves the presence of increased levels of peptides, specifically, pancreatic polypeptide PYY, known to increase appetite. Increased levels of PYY have been found in some individuals with bulimia.32

Both obesity and a history of dieting are risk factors for bulimia. Individuals with bulimia have eating binges during or immediately following a diet. Psychological factors and family history of eating disorders also appear to be related to the development of bulimia. Depression, affective disorders, anxiety disorders, substance abuse, and a history of sexual abuse may increase the chances of developing bulimia.21,32

Like individuals with anorexia, athletes and models are thought to be at risk for developing bulimia. These individuals are often placed in front of crowds and judges, which may lead to a preoccupation with weight and body image.

Assessment and diagnosis of bulimia may be difficult given that many individuals with this condition appear to be of normal weight and tend to avoid disclosing their bingeing and purging behaviors. Furthermore, there is no specific laboratory study that will diagnose bulimia. A screening tool that is used in the United Kingdom on individuals suspected of having bulimia appears in Table IV. The five items, called the SCOFF (sick, control, one, fat, food) questionnaire, are designed to identify key features of anorexia and bulimia. Morena states that the falsepositive rate is 12.5% and that the sensitivity rate is very high.32 One point is awarded for each “yes” response. A score greater than two indicates a likely case of anorexia or bulimia.

In suspected cases of bulimia, a body chemistry panel may be used to determine if electrolyte imbalances are present. A cardiac assessment is warranted for individuals who use ipecac to purge. Electromyography should be considered if abuse of ipecac is suspected, or the individual has symptoms suggesting hypokalemia or arrhythmias. Gastric motility studies are recommended for individuals with a prolonged history of bulimia, a history of constipation, or other unexplained abdominal pain.


Binge Eating

Binge eating disorder, also referred to as compulsive overeating, is a recently recognized eating disorder. It is characterized by repeated episodes of uncontrolled eating where the bingeing does not stop until the person is uncomfortably full. This disorder is similar to bulimia nervosa; however, people with binge eating disorder usually do not purge their bodies of the excessive food they consume. Table I highlights the diagnostic criteria for binge eating disorder.

According to the National Diabetes and Digestive Kidney Diseases (NIDDK) of the National Institutes of Health (NIH), approximately 2%, or 4 million Americans, have binge eating disorder. About 10 to 15% of people who are mildly obese have this disorder. The ratio of females to males with binge eating disorder is 3:2.35 Approximately one-quarter to one-third of individuals attending weight loss clinics meet the criteria for binge eating disorder.21 People who become overweight at a younger age and those who lose and gain back weight frequently (the socalled yo-yo diet) are more likely to have binge eating disorder.

The etiology of binge eating disorder is unknown. Depression may be associated with this condition, but it is not known whether depression causes binge eating or is a consequence of compulsive overeating. The presence of nonspecific risk factors for psychiatric disorders, such as adverse childhood experiences and parental depression, as well as a predisposition to obesity appear to increase the likelihood of developing binge eating disorder.21

Individuals who are obese and have binge eating disorder tend to eat large amounts of foods that are high in fats and sugars. As a result, they are at risk for Type 2 diabetes mellitus, high blood pressure and cholesterol, kidney disease and/or failure, gallbladder disease, cardiovascular disease, cancer, menstrual irregularities, depression, suicidal thoughts, and substance abuse.36

Assessment and diagnosis of binge eating disorder includes thorough health, weight, and diet histories. Physical examination—noting height, weight, calculated body mass index (BMI), blood pressure, and waist circumference measurements (for obese individuals)— should be performed. Laboratory testing should be based on historical and physical examination findings.


Pica

An eating disorder less often encountered by oral health professionals is pica. This disorder is typically defined as the compulsive eating of non-nutritive substances for a period of at least one month at an age for which this behavior is developmentally inappropriate (after age 18 to 24 months), and not a culturally sanctioned practice.37,38

The term pica comes from the Latin word meaning magpie and reflects this bird’s peculiar eating habits; they show an indiscriminate preference for food and non-food substances. Non-food substances ingested by individuals with pica appear in Table V.

The prevalence of pica in the United States is unknown. This eating disorder is frequently unrecognized and underreported. Pica is frequently observed in children, individuals with developmental disabilities, and pregnant women. Children with mental retardation and autism are affected more frequently, and the severity of pica increases with increasing severity of mental retardation.37

Pica behavior is also known to occur ritualistically in some cultures. Geophagia (clay ingestion) is the most common form of pica, occurring in tribe-oriented societies as well as in people living in the tropics. It was a common act during the 1800s in the southern United States, primarily among slaves. Pica has been practiced as part of religious ceremonies, magical beliefs, and attempts at healing.39

The etiology of pica remains unknown; however, numerous hypotheses have been proposed to explain this unusual phenomenon. Cultural, socioeconomic, organic and psychodynamic factors have been cited as causes. Nutritional deficiencies of minerals, iron, and zinc appear to be a common theory concerning the etiology of pica. Sayetta reported studies of individuals with pica with low iron and zinc levels whose pica behavior diminished when iron or zinc supplements were given.40 However, empirical evidence remains unconfirmed. Sensory and physiologic theories focus on the finding that individuals with pica claim to enjoy the taste, texture, or smell of the item they are eating. Psychosocial theories related to pica have examined the association of family stress such as maternal deprivation, parental separation, parental neglect, and child abuse involving pica. Investigations have examined an underlying biochemical disorder, like a diminished dopaminergic neurotransmission, but correlations have not been identified empirically.37,38

Others have proposed that pica is part of the obsessive-compulsive disorder (OCD) spectrum of diseases, in which practicing a ritualistic behavior leads to relief of tension and anxiety.41,43 Risk factors for pica include parental/child psychopathology, family disorganization, environmental deprivation, pregnancy, epilepsy, brain damage, mental retardation, and developmental disorders.37

Manifestations of pica vary and include inherent toxicity, obstruction, excessive caloric intake, nutritional deprivation, infection, and injury. Of concern is the toxicity associated with ingestion of lead or other heavy metals. Physical manifestations of lead poisoning can include neurologic (e.g., irritability, lethargy, incoordination, headache, cranial nerve paralysis, seizures, coma, and death) and gastrointestinal (e.g., constipation, abdominal pain, colic, vomiting, anorexia, diarrhea) symptoms. Gastrointestinal symptoms, such as mechanical bowel problems, ulcerations, perforations, and obstructions may occur due to ingesting substances that are undigestible, such as hair eating. Infections and parasitic infestations are also a concern. Toxocariasis is the most common soil-borne parasitic infection associated with pica and can lead to fever, hepatomegaly, malaise, cough, myocarditis, encephalitis, retinal lesions, and loss of vision.

Diagnosis of pica can be difficult and frequently depends on selfreporting. Accurate diagnosis is often hindered by reluctance to report the practice as well as the secretiveness on the part of individuals with pica and their families. In suspected cases, laboratory studies that may be performed include a complete blood count, iron level, ferritin level, lead level, electrolytes, and liver function studies. Abdominal radiographs, upper and lower GI barium examinations, and an upper GI endoscopy may be needed to evaluate for intestinal obstructions, bezoar formation, or parasites. Stool cultures can be used to rule out ova and parasites. Parents should be interviewed about the dietary habits and pica behaviors of children. Furthermore, individuals with pica symptoms may be assessed for OCD and impulse control disorders through psychological evaluations.


Medical Management and Prognosis of Eating Disorders

Treatment of anorexia consists of medical management, psychotherapy, and nutrition counseling. The goals of treatment are to normalize body weight, correct the preoccupation with weight loss, and prevent relapse. Monitoring weight, vital signs and serum electrolytes is essential. Weight gain should not be excessive. Rapid refeeding can lead to excessive bloating, edema, and in rare instances, congestive heart failure.44

In some cases of anorexia, antidepressants may be indicated, although studies have demonstrated little benefit in using antidepressants during the weight-gain phase of treatment.21,45 However, tricyclic antidepressants are contraindicated individuals who present with prolongation of the QT interval on an ECG. This finding, coupled with tricyclics, can increase the risk of ventricular tachycardia and death.8

For those individuals presenting with osteopenia, dietary calcium 1000 to 1500 mg/d), vitamin D (400 IU), and routine bone density examinations are recommended.1,21 The benefits of estrogen replacement for this condition in individuals with anorexia have not been established.

Family therapy is often used to address the psychological health of individuals with anorexia. Psychodynamic psychotherapy, in combination with behavioral strategies, is helpful in addressing issues of body image, weight management, and predisposing and precipitating factors associated with anorexia.12,46,47

Nutrition is a vital component of treatment for individuals with anorexia. A registered dietician should be an integral part of the treatment team and will provide education on nutrition, adjustment caloric and nutritional intake, limitations on exercise, and will monitor the diet to avoid the refeeding syndrome.

Limiting physical exercise is recommended as part of the treatment for anorexia, which limits energy expended and contributes to a balanced weight. Limiting physical activity is also used as a motivational strategy to help maintain healthy eating habits so the individual with anorexia can return to favorite sports or exercise routines.

Although most treatment for anorexia can occur in outpatient settings, those who are at risk medically and/or psychiatrically, require inpatient care. Indications for inpatient treatment include low or rapid weight loss, severe electrolyte imbalance, temperature less than 36ºC, pulse less than 45 BPM, altered mental status or other signs of severe malnutrition, cardiac disturbances, psychosis, or high suicidal risk.12

The prognosis for individuals with anorexia remains guarded and depends on a variety of prognostic factors such as age of onset, weight loss at diagnosis, duration of symptoms, duration of inpatient care, and state of family relationships. Onset of anorexia before adulthood carries a more favorable outcome. However, when onset occurs at an age younger than 11 years the prognosis is poor. Ashort duration of involvement of the organ systems, short inpatient treatment period, and a good relationship between the parents and child tends toward a more favorable outcome.

The mortality rate in anorexia is 10 to 20%. In general, 50% of individuals with anorexia recover completely, while 20% remain emaciated, 25% are thin, or 5 to10%, die of starvation.12,21,48

Treatment of bulimia includes nutrition counseling, medications, and psychotherapy. Nutrition counseling is used to guide individuals toward normal eating patterns and healthy food choices. Reintroducing“feared” foods in small amounts is used to teach those with bulimia to enjoy these foods without needing to overeat.

The most commonly prescribed medications for individuals with bulimia are antidepressants, such as Prozac and Norpramin. These medications help relieve depressive symptoms associated with bulimia nervosa and help individuals achieve a more healthy body image. In some cases, antiemetics, such as Zofran, are prescribed on a shortterm basis at the onset of treatment to help reduce the stimuli to vomit.

Counseling, particularly cognitive behavioral therapy (CBT), is used to encourage rational attitudes about weight, moderation of high self-expectations, enhancement of self-esteem, and alleviation of stress. CBT helps people with bulimia to systematically challenge their assumptions linking weight to selfesteem, while the individual with bulimia is encouraged to set the treatment goals, family involvement in treatment also is encouraged.

The prognosis for individuals with bulimia also remains guarded. A 10-year follow-up study found that 52% of people with bulimia had recovered fully and 9% continued to experience symptoms of bulimia.49 A study of 222 individuals treated with antidepressants and intensive group therapy found that after 11.5 years, 70% were in full or partial remission, but 11% still met the criteria for bulimia.50 Although cognitive-behavior therapy and medication have shown to benefit those with bulimia, they fail in approximately one-third to one-half of cases. Relapse rates are around 30%.21,32 A good prognosis has been associated with shorter duration of illness, younger age of onset, and higher social class.40 Poor prognosis has been associated with a history of substance abuse, premorbid and paternal obesity, and personality disorder.50,55

Current treatment for binge eating disorder includes cognitivebehavioral therapy, interpersonal psychotherapy, drug therapy, and a supervised weight loss program. Cognitive behavioral therapy involves keeping track of eating habits and methods for changing unhealthy eating behaviors. Interpersonal psychotherapy focuses on relationships with friends, family, and eating. Antidepressants are helpful in treating depression and other mood disorders that may be associated with binge eating. Fluoxetine has been found to be effective in decreasing the frequency of bingeing episodes. Greeno and Wing noted a decrease in caloric intake of more than 60 kcal/d in the treatment group receiving fluoxetine when compared with the placebo group. The authors suggested that the effect of this medication is to induce satiety rather than to decrease appetite, as there was no decrease in the frequency of eating noted.56 Finally, the NIDDK recommends that individuals with binge eating disorder seek a supervised weight loss program that also offers treatment for eating disorders as the best approach for successful weight loss.35

The prognosis for binge eating is circumspect. Supervised weight loss with psychotherapy may offer the best results. For more information concerning this eating disorder, the reader can contact the Weight-control Information Network at win@info.niddk.nih.gov.

Treatment of pica is focused on education, behavior changes, diet, and medical intervention for specific problems such as anemia, gastrointestinal obstruction, or infection. Diet analysis, assessment of nutritional beliefs, and nutrition counseling also are appropriate interventions. Psychological counseling or behavior therapy can be useful adjuncts, especially for individuals with OCD and children with developmental disabilities. Behavioral strategies that have been effective are antecedent manipulation; discrimination training between edible and inedible items; contingent aversive oral taste (lemon), smell sensation (ammonia) and physical sensation (water mist); overcorrection (correct the environment or practice appropriate alternative response); and reinforcement.57 Parents of children with pica should be instructed to provide closer supervision of children during play and to child-proof their home and play environments. The removal of toxic substances from the environment, particularly lead-based paint, is important.

Not all forms of pica are dangerous and cause medical complications. Pica frequently remits spontaneously in young children and pregnant women. However, it may persist for years in individuals with mental retardation and developmental disabilities. Long-term follow-up with psychological and nutrition counselors may be warranted in such cases.


Oral Manifestations of Eating Disorders

The eating disorders that tend to present with oral manifestations are anorexia nervosa and bulimia nervosa. Literature concerning specific oral manifestations of binge eating disorder and pica has not been described. However, individuals with pica presenting with iron deficiency anemia may present with glossitis (sore, smooth, and/or redness of the tongue), xerostomia, and dysphagia.58,59

Oral health findings of anorexia and bulimia vary in severity with the length of time the individual has the disorder, the degree and frequency of pathological eating behaviors, diet, and oral hygiene habits. The most common oral manifestations of eating disorders affect the dentition, salivary glands, periodontium, and oral mucosa.

The most common effect of anorexia and bulimia is tooth enamel erosion or perimylolysis associated with the chronic regurgitation of gastric contents.60-65 Hellstrom defined this condition as “a loss of enamel and dentin on the lingual surfaces of the tooth as a result of chemical and mechanical effects caused mainly by regurgitation of gastric contents and activated by movements of the tongue.”66 The hydrochloric acid contained in vomitus breaks down the enamel and dentin of the teeth as it moves through the oral cavity. Perimylolysis is usually clinically observed after the individual has been purging for at least two years.68 Miloslevic and Slade studied the orodental health of individuals with anorexia and bulimia. Findings indicated that enamel erosion only may be evident in those individuals who demonstrate frequent regurgitation. These investigators found a relationship existed between vomiting episodes and abnormally high erosion, but only when the frequency of vomiting was greater than 1,100 episodes.68

The erosion associated with eating disorders typically has a smooth, glassy appearance particularly on the palatal surfaces of the maxillary anterior teeth (Figure 1). Severe generalized destruction may occur to the extent that the pulps of the teeth may be visible. Clients with this severity of erosion may complain of thermal sensitivity, and occlusal changes. The margins of restorations on posterior teeth may appear to be ‘floating’ or higher than adjacent tooth structures (Figure 2). Other occlusal changes include anterior open bite and loss of vertical dimension caused by loss of occlusal and incisal tooth structure.10 Bruxism and clenching and abnormal swallowing habits also may contribute to loss of tooth structure.69

Some individuals demonstrate buccal erosion of the enamel surfaces. Figure 3 demonstrates erosion of the facial surfaces of both the maxillary and mandibular anterior teeth. This finding has been attributed to excessive consumption of citrus fruit drinks as part of the diet of persons with eating disorders or as a result of medications prescribed by physicians for those with anorexia. Dextrose tablets and sucrose containing vitamin C beverages have been used in the treatment of individuals with anorexia.69

The incidence of caries among persons with eating disorders appears to be variable. Individuals with anorexia tend to ingest a lower than normal amount of food. However, the proportion of carbohydrates to protein and fats is higher than in the normal population. Persons with bulimia tend to ingest high amounts of carbohydrates during episodes of binge eating. Likewise, those with binge eating disorder consume large amounts of carbohydrates. Ahigh-carbohydrate diet can lead to an increase in acid production and an increase in the risk of dental caries.

Empirical studies examining the caries rate in individuals with anorexia and bulimia reveal conflicting results. Hellstrom reported a low caries rate in one study of anorectic subjects66 and a moderately high rate of caries in a subsequent study.68 Stege, Visco-Dangler, and Rye reported a case study that revealed a high caries rate in an individual with anorexia. They attributed this finding to bingeing on high-carbohydrate foods and citrus fruits and poor oral hygiene.70 Milosevic and Slade failed to find differences in caries rate between eating disorder subjects and control subjects when comparing bitewing radiographs, DMFT scores, and the buffering capacity of saliva.68 Liew, et al. investigated the level of bacteria implicated in caries development among anorexic females and control subjects. The results of this study indicated that the anorexic and control subjects did not differ in the level of bacteria associated with caries development, salivary flow rate, or DMFT scores.71

Enlargement of the parotid glands and occasionally the sublingual glands is a frequent oral manifestation of the binge-purge cycle of individuals with eating disorders.72 The incidence of parotid swelling has been estimated to be between 10 and 66%.73 The enlargement may be unilateral or bilateral.72 The parotid swelling is soft to palpation and painless. The duct appears to be patent with a normal salivary flow and the absence of inflammation. Tylenda, et al. found greater acinar size, increased secretory granules, fatty infiltration, and noninflammatory fibrosis associated with parotid changes in individuals with bulimia.74

The occurrence and severity of parotid swelling is related to the frequency, duration, and severity of the binge-purge cycle.75 Frequent vomiting may cause a chronic work hypertrophy or an autonomic neuropathy that leads to enlarged acinar cells.76 The onset of swelling follows a binge-purge episode by two to six days.73 Initially, the enlargement may be intermittent, but eventually, it can persist. This results in a cosmetic deformity that may compel the individual to seek treatment because it affects his/her psychological state.

Reductions in salivary flow rates and xerostomia have been found in individuals who binge eat and induce vomiting or abuse laxatives and diuretics.70,74,77 Xerostomia is also a common side effect of psychotherapy medications, particularly antidepressants, prescribed for the treatment of eating disorders.

Individuals with anorexia or bulimia tend to be relatively young; therefore, they rarely have advanced periodontal disease. However, persons with eating disorders may exhibit poor oral hygiene resulting in increased gingival inflammation and gingival erythema. 63,78 Poor oral hygiene is more common in individuals with anorexia than in those with bulimia. Generally, persons with anorexia are more prone to depression and manifest less interest in oral hygiene practices. Individuals with bulimia tend to be more concerned about their appearance and are more meticulous about their oral hygiene.10

Those who binge eat and purge may demonstrate trauma to the oral mucous membranes and the pharynx. The rapid ingestion of large amounts of food and the force of regurgitation have been implicated as the cause of trauma to these tissues.61 Objects used to induce vomiting—such as fingers, combs, and pens—can cause injury to the soft palate. Other changes in the oral tissues that may be noted include dehydration, erythema, and angular cheilitis.67,78


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.


Conclusion

Eating disorders present a challenge for oral health professionals with respect to assessment, diagnosis, and treatment. Nevertheless, dental hygienists and dentists can advocate intervention and are important in the treatment process. It is imperative that oral health professionals remain alert to signs and symptoms of eating disorders, and offer alternatives to assist the client in restoring oral health and recovering from their condition.


Organizations/Sites for More Information

Eating Disorders Awareness and Prevention, Inc.
603 Stewart St., Suite 803
Seattle, Washington 98101
Phone: 206/382-3587 or 800/931- 2237
www.edap.org

National Eating Disorders
Organizations
6655 South Yale Avenue
Tulsa, Oklahoma 74136
Phone: 918/481-4044

Academy for Eating Disorders
6728 Old McLean Village Drive
McClean, Virginia 22101-3906
Email: aed@degnon.org
www.acadeatdis.org

Behavioral Medicine
Stanford Outpatient Psychiatry
401 Quarry Road
Stanford, California 94305
Phone: 650/498-9111

Center for Overcoming Problem Eating and Eating Disorder Clinic Western Psychiatric Institute and
Clinic
3811 O’Hara Street
Pittsburgh, Pennsylvania 15213
Phone: 412/624-5420

Eating Disorders Clinic
New York Psychiatric Institute
1051 Riverside Drive
NYSPI Unit 98
New York, New York 10032
Phone: 212/543-5739

Eating Disorder Research Program
University of Minnesota
2701 University Avenue, SE
Suite 206
Minneapolis, Minnesota 55414
Phone: 612/627-4494

Rutgers Eating Disorders Clinic
GSAPP, Rutgers University
Box 819
Piscataway, New Jersey 08854
Phone: 732/445-2292

Center for Eating and Weight Disorders
San Diego State University
6495 Alvarado Road, Suite 200
San Diego, California 92120
Phone: 619/594-3254

Weight and Eating Disorders Program
University of Pennsylvania
3600 Market Street
Philadelphia, Pennsylvania 19104
Phone: 215/898-7314

Yale Center for Eating Disorders Program
Yale University, Department of
Psychology
P.O. Box 208205
New Haven, Connecticut 06520- 8205
Phone: 203/432-4610

Eating Disorder Program
Adolescent and Young Adult Medical Group
Children’s Hospital at Strong
610 Elmwood Avenue, Box 690
Rochester, New York 14642
Phone: 716/275-7844

Child and Adolescent Eating Disorders Programs
Menninger Clinic
P.O. Box 829
Topeka, Kansas 66601-0829
Phone: 800/351-9058

Lifespan Weight Management Programs
The Miriam Hospital Center for Behavioral and Preventive Medicine
164 Summit Avenue
Providence, Rhode Island 02906
Phone: 800/927-1230

Weight Control Information Network
1 Win Way
Bethesda, Maryland 20892-3665
Phone: 202/828-1025 or 877/946- 4627
Fax: 202/828-1028
Email: win@info.niddk.nih.gov


Supplemental Activities

  1. Present an eating disorder case as part of a study club activity. Invite other health care providers to attend the study club session. Discuss any observed oral manifestations of the disorder, assessment methods used, and the role of each health care professional involved in active treatment and supportive care.
  2. Visit Web sites to gain additional information on eating disorders.
  3. Attend continuing education courses that provide a strong scientific foundation concerning the medical and psychological effects of and treatment for eating disorders. Discuss the role of oral health professionals in meeting the needs of individuals with eating disorders.
  4. Collaborate with a registered dietician and design an assessment tool for the dental practice setting that addresses patients' weight history and eating habits. Use information gained from this tool as part of preventive education and home care instruction sessions with clients that appear to be at risk for an eating disorder.
  5. Examine assumptions concerning eating disorders. Think about the relationship between food in your life and your weight. Identify how your attitudes and behaviors, as well as those of others close to you, have affected your perceptions of body image and ideal weight.
  6. Develop a brochure on eating disorders and oral health. Include a list of resources for additional information that includes recommendations for seeking help.
  7. Design a community awareness program on eating disorders and oral manifestations that can be offered at health fairs, in school systems, and at parent-teacher organizations.


Key Terms

Anorexia Nervosa – a disorder characterized by refusal to maintain body weight over a minimum normal weight for age and height, an intense fear of gaining weight, and distorted body image.

Amenorrhea – absence of menses.
Bezoar formation – a mass formed in the stomach by compaction of repeatedly ingested material that does not pass into the intestine.
Binge eating – a disorder characterized by repeated episodes of uncontrolled eating such that the bingeing does not stop until the person is uncomfortably full.
Bulimia Nervosa – a disorder characterized by binge eating and purging behaviors (a minimum of two binge-eating episodes a week for at least three months), and persistent over concern with body shape and weight.
Cholestasis – stoppage or suppression of bile flow due to factors within or outside the liver.
Hepatomegaly – enlargement of the liver.
Hypercarotenemia – the presence of excessive carotene in the blood usually resulting from excessive ingestion of carotene-containing foods; may also be present in diabetes mellitus and hypothyroidism.
Hypochloremia – an abnormally low level of chloride in the blood.
Hypokalemia – abnormally low potassium concentration in the blood.


About the Author

JoAnn R. Gurenlian, RDH, PhD, is an internationally recognized author, research consultant, and speaker. Gurenlian is the owner of Gurenlian and Associates, offering consulting and continuing education services to health care professionals. In addition to having clinical experience in periodontal, general, pediatric, and orthodontic practices, she currently works part-time in a medical practice enhancing her assessment and diagnostic skills.