NCEED Webinar 5 Transcript

[email protected]: Hello everyone and welcome to today's webinar. We are truly appreciative of you guys attending. A few things to note. All participants will be muted upon entry and videos turned off. For technical assistance, please use the chat box. You will also receive an email in approximately three months requesting feedback/impact on this presentation and we would also like, for you to visit www.nceedus.org/trainingto view other training opportunities that NCEED has to offer.

[email protected]: I will now go ahead and introduce today's speaker, Miss Brittany Davis.

[email protected]: Brittany Davis is a senior dental student at Columbia University College of Dental Medicine. She received her B.E. in Chemical Engineering at Vanderbilt University and worked as a software consultant before pursuing . Throughout her four years in dental school, Brittany focused her studies on an interprofessional model for patient care. She leads a research group studying dentist’s role in identification and symptomatic management of eating disorders. She is collaborating with the Academy for Eating Disorders, to incorporate dental guidelines into a medical standards guide. And she serves as a member of the Inter professional national dental association, where she works alongside and multidisciplinary healthcare team to address modern barriers to comprehensive patient care. Brittany, has been accepted into Emory University's combined Medical School and oral and maxillofacial surgery residency Program.

[email protected]: Over the next six years she will receive her MD degree from Emory, become a credential surgical specialist, and continue expanding her vision to a teams-based approach to patient care. I'll now turn things over to Miss Brittany Davis.

Brittany Davis: Hello everyone, and thank you so much for donating your time to be here tonight. I really appreciate it.

Brittany Davis: So just to move forward with things today we're going to be speaking about oral health and the title of this presentation is ”Preservation of Oral Health and Eating Disorders: An Essential Guide for Health Professionals.”

Brittany Davis: And again, my name is Brittany Davis, and I am from Columbia University and graduating in about a month.

Brittany Davis: So, to give some background, as to why this topic is even important. Eating disorders are very important and severe and largely prevalent. Some studies say upwards of 1% of Americans have been diagnosed or could be diagnosed with and 2% could be diagnosed with .

Brittany Davis: These percentages encompass a whole wide range of people, it's not necessarily just young teens it could be older adults. Men and women and, if anything, these numbers are likely still underestimated and a failure to treat these eating disorders can cause some pretty critical consequences. It leads to some serious systemic health conditions it can lead to irreversible bodily harm and, unfortunately it can lead to death. It does have a mortality rate that's pretty high when compared to other psychological disorders and so researchers found that early intervention is the single most important factor in terms of having a positive long term outcome for this population.

Brittany Davis: So now, the reason why dentist getting involved is so important is because number one, dentists see a wide range of patients. That could be with our pediatric dentist who see kids, orthodontists who classically see teenagers, general dentists, see the people of all ages process the dentist may be working with an older population oral surgeons again can be any age group and classically that 17 to 18 year old age group of who get their wisdom teeth out. So we really can see people across all ages and also we're one of the only health providers that are giving a comprehensive oral exam and research has shown time and again that there are quite a number of symptoms that present through eating disorders and present through the mouth so you know it's really up to us to catch those oral symptoms. And again dentists we have regular recall, ideally, we like to see patients every six months, potentially more which gives us a great opportunity to really catch these early symptoms and hopefully we're developing trusting relationships with our patients having worked with them for potentially years in and out.

Brittany Davis: And it has been acknowledged that a dentist and maybe the first provider to encounter an undiagnosed eating disorder, so it really is our responsibility to kind of be in tune to these symptoms and speak out when we see something.

Brittany Davis: Just for some basic background the DSM-V diagnostic criteria for both Anorexia and Bulimia. For Anorexia, it can be defined as the restriction of energy intake, causing a significantly low body weight. And since fear of gaining weight and excessive influence of your weight or shape influence your self-evaluation, in Anorexia it can be broken into restricting type versus the binge-eating/ purging type.

Brittany Davis: And then, on the other end of the spectrum, we have Bulimia which is known as having a current episodes of binge eating, followed by recurrent compensatory behaviors to prevent weight gain and that can look like and come in many different forms, whether that's .

Brittany Davis: The improper use of laxatives, or diuretics or fasting. And again just like anorexia, there's this excessive influence of the way your body weighs or shape in the way that you self-evaluate and, of course, there are it's a large spectrum, there are people who fall in between, and may not meet the exact criteria for just one or the other, so again there's plenty of people to watch out for.

Brittany Davis: And so for today's webinar we've got three pretty basic learning objectives. By the end of this, the hope is that you'll be able to describe the oral signs and symptoms associated with eating disorders. That you will be able to compare treatment and intervention options for patients who are showing these symptoms, and finally be able to prepare some risk reduction strategies for patients who are experiencing or have active or relapsing episodes of disordered eating.

Brittany Davis: So to start, I would like to talk about acid erosion and that's probably one of the most classic oral symptoms that anybody thinks about regarding eating disorders and our oral health and acid erosion comes into primary forms, intrinsic acid erosion and extrinsic erosion.

Brittany Davis: So for some basic anatomy, our teeth are made up of several layers. Our outer layer is called enamel. Just under that is the dentin layer and then beneath all that is the pulp chamber which carries our blood vessels in our nerve supply.

Brittany Davis: So, in terms enamel, that has a critical pH of 5.5, any pH that begins to dip lower than that or becomes more acidic is when the enamel erosion begins. At that point, it no longer can maintain its integrity.

Brittany Davis: And at the incisal edge of the tooth, when we get that enamel thinning that will appear as a translucent edge.

Brittany Davis: In more so in the body of the tooth when we get that enamel thinning will see it as yellow the color, yellow coming through and that's because dentin underneath enamel is yellow and so we'll start to see its color.

Brittany Davis: And here's some examples of what that can look like on the left, we see that very thin translucent enamel at the incisal edge and on the right side we see some examples of that pronounced yellow color coming through as the enamel at the body of the tooth just being eroded away.

Brittany Davis: So first talking about intrinsic acid erosion, that's defined as that is contacting the teeth.

Brittany Davis: And that can be due to self-induced vomiting. However, it can also be due to other diseases such as gastroesophageal reflux disease, so it doesn't make it a bit different to differentiate between the two, which is something to really note in the clinic.

Brittany Davis: And intrinsic acid erosion is primarily noted for its effect on the palatal surfaces of the maxillary anterior teeth, so all that to say it is on the inside surface next to our tongue of our upper arch of our front teeth is where we will really see that erosion coming through. And then in later stages will also start to see it affect the occlusal surfaces, which are the biting surfaces of both the maxillary and mandibular posterior teeth.

Brittany Davis: And there has been a term given specifically to this type of erosion called perimylolysis and it is characterized by the smooth, glossy appearance free of staining. It's very classic for any sort of intrinsic acid erosion and so here's one example where we can see on the palatal surface, we've got some erosion going on and pretty smooth and glossy.

Brittany Davis: Another more pronounced example, we can see even more severe erosion, particularly on these posteriors. Then, here we can I mean even more clearly see that erosion, so much so that we can see physically that DEJ, the dental enamel junction where this yellow body is the dentin and this white outer layers is the enamel and the acid is really chipping right through that protective enamel.

Brittany Davis: Now here's an interesting picture because intrinsic acid erosion is really characterized by this smooth glossy erosion that's free of staining. So if you see teeth that have been worn down by erosion that are beginning to stain, it actually can hint that the behaviors have begun to stop and that. Potentially this patient may not be in a very active period where they are bingeing and purging or vomiting, and for that reason the teeth have now been allowed to stain.

Brittany Davis: And then, finally, this is actually a case of GERD, which looks very similar to the acid erosion we see with reflux self-induced vomiting. However, this patient in particular sleeps on their left side, and so, for that reason they have nocturnal reflux primarily, which is why we see erosion only affecting the one side, so just very small details we can use to try to get a better a better picture of what's going on with our patients.

Brittany Davis: Next, moving on to extrinsic acid erosion. Extrinsic acid erosion means the consumption of acidic food or drinks, so that can be anything such as sports drinks, diet soda, raw citrus fruits anything like that, and this is more so seen with anorexia nervosa bringing in foods that are very low calorie to prevent oneself from intaking too many calories. And with extrinsic acid erosion, the pattern is going to be on the buccal or outer surface labial surface of the occlusal teeth and it has a more dished out appearance so it's pretty distinct from the intrinsic acid erosion, which we saw on the inner surfaces of our teeth, particularly our upper arch those front teeth.

Brittany Davis: So some examples. Here we have on the outer surface this dished out appearance of these posterior teeth.

Brittany Davis: And again, another great example, you can see, this dished out appearance from the extrinsic acid, so acids that we're consuming. And finally, one more picture.

Brittany Davis: So now, the clinical correlation to all this. First these sort of lesions can be seen anywhere between six months after the behaviors begun upwards of two years into the behavior six months.

Brittany Davis: Just very severe behavior in two years, being more close to the average according to the research.

Brittany Davis: And after we've had sort of erosion, the patient is going to be very sensitive to hot cold, touch, and air.

Brittany Davis: It can even get to a point where it's so severe that the patient will complain of sensitivity with just brushing their teeth even that amount of pressure will be painful for them. And with erosion we're eroding away the surfaces of our teeth so over time that's when it becomes shorter and that has a handful of consequences by itself.

Brittany Davis: Number one, it may lead to something that we call an anterior open bite. When you close your mouth, all the way, your front teeth still aren't in contact there's a little bit of space.

Brittany Davis: We can see a compensatory eruption of the teeth opposite those that have been eroded away to come in and try to meet their partners.

Brittany Davis: A loss of VDO (vertical dimension of occlusion) means that me to run an overall the other sort of look. And then also we will see high seating restoration margins, meaning that the tooth itself will be eroding away, but the amalgam fillings or the composite filling will be standing strong unaffected by the acid, and it will be a noticeable difference. They'll no longer be flush and of course this causes poor aesthetics for the patient.

Brittany Davis: And so, some examples of an anterior open bite here the patient is closing all the way, we can see that their posteriors are and maximum interpretation, but there is still this space where their front teeth aren't quite coming together.

Brittany Davis: And then compensatory eruptions, so I give this picture as an example of what our normal smile line should look like on top here we see that the upper teeth.

Brittany Davis: Kind of follow the shape of the lower limit in the shape of a smile here on the lower side, we see that these teeth have had severe erosion. And so, her lower teeth have erupted, even more so to meet them, however, now her smile line is almost in the shape of a frown opposite of her lips smile line.

Brittany Davis: If there is no compensatory eruption, then we may see what we call a loss of vertical dimension of occlusion.

Brittany Davis: In the most severe case, this is kind of what we see with patients who wear dentures.

Brittany Davis: When they take their dentures out you see that their maxilla and their mandible come even closer in relation to each other, and that is possible to develop with their severe eating disorders, often more so in an older population who's suffering with an eating disorder.

Brittany Davis: And finally, this is what high restoration margins might look like, so the tooth structure itself, and particularly here is eroding away, but that silver filling is just standing just as high as when it was placed.

Brittany Davis: So Next, I would like to talk about , which is a fancy word for low salivary flow, and before I can get too much into that, I have to explain how caries develop in the first place. So first, we have what we call a pellicle formation. Caries

Brittany Davis: develop due to the bacteria that are colonizing our tooth surface they kind of stick along the surface and what we call a pellicle and more and more bacteria of different types start to accumulate and add on to that pellicle and cause plaque formation, as they start to build up and clump together and colonize.

Brittany Davis: And then eventually those bacteria they start to feed off of carbohydrates, so they eat what we eat. They feed off the carbs and they secrete acid, in return, and that acid that they secrete is then what we call a cavity or caries.

Brittany Davis: And that acid is what chews away into our tooth and that's when a cavity needs to be filled.

Brittany Davis: So is just abundantly important for trying to stop the process. Saliva has some pretty cool functions, the first which being bacterial clearance.

Brittany Davis: Within our saliva we have these things, called glycoproteins that can cause bacteria to clump together and be washed away as we swallow, be washed away with our saliva.

Brittany Davis: We have buffering acids in our saliva things like bicarbonate is a huge one and it helps to neutralize the acid that that the bacteria are secreting to help promote a healthy space that our teeth can survive within and not deteriorate.

Brittany Davis: We have plenty of anti-microbial agents like lactoferrin or immunoglobulin A. All these things coming together to help either kill bacteria or to neutralize them or to prevent them from rapidly spreading. Finally within our saliva we have nutrients for remineralization. So things like phosphate ions, zinc, fluoride all of these ions actually incorporate into our tooth structure and help rebuild its foundation so, even if we have an incipient cavity, a very small lesion.

Brittany Davis: Before we hit the point of no return, there is a point where we can reincorporate some of these ions into our tooth structure and rebuild the foundations that it's strong again, and it is not overcome by capitated cavity.

Brittany Davis: And so all of this to say is if somebody is experiencing low saliva flow, so they're losing out on a whole lot of benefits to prevent cavity formation.

Brittany Davis: So there are quite a number of causes for low saliva flow. Some of it can be due to the salivary gland function, particularly if somebody is engaging in bingeing and purging habits, you may see some change function in their product gland and there may be less production of saliva due to that.

Brittany Davis: Also, with SSRI medications selective serotonin reuptake inhibitors. It's an antidepressant that is commonly prescribed, has known side effect of reducing saliva flow.

Brittany Davis: So that's definitely a big one to look out for in this patient population who very likely could be on an SSRI that could be aggravating that low saliva flow.

Brittany Davis: And then, also a simple dehydration can really influence the flow rate dehydration can come from anything, such as fasting.

Brittany Davis: Self-induced vomiting, intensive exercise, abuse of laxatives, and abuse of diuretics. All these together would produce a low saliva flow.

Brittany Davis: And now just transitioning to a few other oral symptoms that are more commonly seen-- parotid hypertrophy. So that is the recurrent non-inflammatory gland enlargement of the parotid gland. And based upon where it's located it gives us wide sort of square appearance, to the mandible and the hypertrophy will occur roughly two to six days following a binge-purge cycle.

Brittany Davis: The interesting thing about it is that the swelling is soft to palpation and it's painless to the patient and numbers have been sort of all over the place in the research, but kind of agreed upon that there's about a 10 to 50% prevalence of parotid hypertrophy. Along with a cycle of purging habits and in the early stages. This swelling is intermittent it will come and it will go. And although it's reversible but in the later stages, if the habits are prolonged for a great deal of time. It's possible that there may be a permanent deformation of that swelling with only surgical correction being the option at that point. So it's very important to stress to our patients that you know if they're able to kind of curtail these habits.

Brittany Davis: You know the swelling is something that does not have to last forever potentially it is reversible on its own.

Brittany Davis: And here's just a picture of the classic look. We've got that square sort of bulge at the angle of the mandible. And again that's going to be about two to six days following the binge-purge cycle.

Brittany Davis: And then just some more examples, it can be unilateral or can be bilateral.

Brittany Davis: And this is where the product parotid glad is located, which explains why it's such a classic presentation.

Brittany Davis: Now we also know that patients with eating disorders, often present with nutritional deficiencies as well.

Brittany Davis: And there are quite a number of nutrients that affect the mouth so zinc and copper both aid in preventing enamel acid solubility, so being deficient in either of those will lead to easier erosion.

Brittany Davis: Vitamin D deficiency has been linked to worse outcomes of periodontitis and gingival inflammation. Vitamin A is pretty critical in maintaining the salivary glands. So a deficiency in vitamin A can lead to salivary gland atrophy which then leads to a low salivary flow and all those other sort of things that come with it, that we spoke about, and then the B vitamins a deficiency in those you can see.

Brittany Davis: A burning mouth or burning mouth or burn tongue syndrome, cracked lips, oral ulcers, angular , and sore throat.

Brittany Davis: A calcium deficiency. As we all know, calcium is very important for the integrity of our bone and the alveolar bones supporting our teeth is included in that.

Brittany Davis: An iron deficiency often leads to what we call Pica, and a classic sign of Pica is this want to chew ice, which you know, is not at all great for our teeth.

Brittany Davis: And then finally vitamin C. A vitamin C deficiency is pretty rare in this day and age, however, if it were to occur in some very severe circumstance then it would compromise our periodontal ligament health, which is the ligaments that connect our teeth to the bone you would see and spontaneous bleeding.

Brittany Davis: And for just the last few pictures, this is what looks like. It's this red cracked appearance up the corners of the mouth. It's certainly pretty painful so a deficiency in B vitamins can lead to this. Nutritional deficiencies over all.

Brittany Davis: Often times, can lead to , which can present in many different ways, on the left here, you see what would be called a median rhomboid , which is still oral candidiasis, with this classic sort of red bald spot in the middle. Oral candidiasis is this white film that be scraped off. That's kind of how you distinguish it from some other lesions that have a white coating on the tongue.

Brittany Davis: So now goals for dental intervention overall as dentists, we want to reduce the frequency of the oral acid exposure to these patients, we want to enhance their salivary flow.

Brittany Davis: We want to try and neutralize the acids that do interact in their mouth, we want to support enamel resistance to mineralization.

Brittany Davis: In want to minimize abrasive habits, preserve remaining tooth structure, and delay complex restorative treatment until habit has resolved. So in office considerations fluoride is certainly our friend here.

Brittany Davis: There are many different ways to apply fluoride whether that's an in-office topical or prescription daily rinse that the patient can take home or creating custom trays so the patient can apply a fluoride gel at home and all of these will help promote the remineralization of tooth structure.

Brittany Davis: We can also make use of desensitizing agents like Gluma to help with just the day-to-day pain and sensitivity that patients are feeling with eroded tooth structure.

Brittany Davis: Also, we can make use of temporary restorations and using conservative treatment again because complex permanent treatment is not likely to hold up for very long if the habits are still sustained and going strong, so that's why we want to start slow.

Brittany Davis: So conservative treatments can be anything like composite buildups, direct or indirect veneers, bonded onlays. Things like that, to kind of boost the patient's confidence and seeing some improvement to their oral aesthetics before.

Brittany Davis: Moving on to the more treatment and then also we can consider things like prescription artificial saliva or over the counter artificial saliva to help again with that low flow. Brittany Davis: And then likely we want to consider more frequent recall for these patients, some of you have three to four month recall, as opposed to every six months, just to really keep track of how their oral health is doing during this time and then, in terms of harm reduction, that we can suggest to our patients.

Brittany Davis: First off, we can suggest that they decrease the amount of acidic food and drink that they intake. They may not be aware how severe of an effect it's having.

Brittany Davis: We can also recommend that they do drink acidic drinks, with a straw, to try to help bypass some of that liquid from their teeth kind of just straight to the back of their throat.

Brittany Davis: For those who participate in self-induced vomiting habits, we can really recommend that they rinse with some sort of water or alkaline solution after vomiting and, more importantly, is to refrain from brushing for at least 30 Minutes. It feels pretty natural to want to brush right after.

Brittany Davis: However, you know our teeth are really sensitive at this point, that where they've just had this acid attack and brushing may make the problem even worse and be abrasive. So just rinsing with water or an alkaline solution and then refraining from brushing and then sipping water throughout the day.

Brittany Davis: Helping with low flow saliva, but just to keep some sort of fluids kind of moving and washing out our mouth, minimizing carbohydrate-heavy snacking or binges.

Brittany Davis: Again kind of going back to the fact that these cariogenic bacteria feed off of carbohydrates. So the more we can minimize the amount of carbs that we're bringing in, the more we can kind of fend off that risk of caries. And then a sugar free gum is an easy way to stimulate saliva flow and then of course we want to use soft-bristle toothbrushes with gentle, circular motions.

Brittany Davis: You know, we want to stay away from those hard bristles even though it may feel like it's getting off all the grit, it can also be brushing off layers of your enamel as well. So soft-bristles only circular motions, instead of these repetitive horizontal motions and, of course, we always want to recommend to our patients that they floss daily as well.

Brittany Davis: Now, here are some of my references. And with that I can open up the floor to any questions anybody may have.

[email protected]: Thank you so much Ms. Davis for the presentation today. As she mentioned, we will begin to open it up for question and answers. I'll ask for you to type your questions in the Q and A box, but there are a few things that I also would like for you to know. At the end of this presentation conclusion. You will receive the evaluation via email for you to complete, and we will also be sending a copy of these slides to you on Monday.

[email protected]: A recording of this webinar will also be available on the NCEED Training Center within one week from today for anyone that would like to refer anyone to this presentation or access the presentation again.

[email protected]: Brittany, they are also asking if it's possible for you to go back to your references slide and just leave those up for people. So thank you all, and I will begin reading the first question.

[email protected]: The first okay, so we have the references up again. Do we have any additional questions in addition to the request for the references?

Brittany Davis: And in terms of references, there are, or more than this, so if anybody really is interested I would love to give you a more comprehensive list of some pretty neat articles that are out there.

[email protected]: We have some people that are saying great webinar and thank you.

[email protected]: Do we have any additional questions at this time.

[email protected]: Okay Brittany, our next question is, “At what point can cosmetic work start?”

Brittany Davis: So, essentially the research and nothing is very set in stone, but the goal is to kind of hold off on cosmetic work until, particularly the binging and purging habit has subsided.

Brittany Davis: The fear being that cosmetic work done while that's still ongoing may fail so if that patient becomes a little bit more stable at that point, by all means.

Brittany Davis: Even if it's just temporary cosmetic work to begin with, just to bump up there, you know just their ego and make them feel a little bit better that you can maybe help in terms of their, just like overall resolve to continue to do better just having a little bit of momentum. So maybe a little bit of temporary cosmetic work and then for the final stuff once those habits have subsided, a little bit.

[email protected]: Okay, thank you. The next question is, “What do you think could be the role of being nutritionist in the dental setting?”

Brittany Davis: Oh that's a great question. I think there's a lot of opportunity for nutrition is to work with dentist.

Brittany Davis: Because you know a lot of our oral health is dependent upon what we put in, so kind of like we spoke about. You know these acidic food and drinks that we're intaking. The types of nutrients that we're bringing in so like carbohydrates, and if that's the primary source of our food.

Brittany Davis: That's going to increase our risk of caries. So and I mean even beyond that our risk of caries is due to not only what we eat, but how frequently we snack, so if we eat just three meals a day, that’s better than five or six tiny snacks throughout the day so goodness, I think a nutritionist kind of alongside a dentist to explain the why, behind why those little changes matter and what they do, would be so important.

[email protected]: Thank you, the next question is, what are the three basic recommendations to achieve good oral hygiene.

Brittany Davis: So three basic recommendations off the top of my head, I would say number one.

Brittany Davis: You know, go to your dentist regularly. That’s, without a doubt, just always make sure that you're being checked by a professional and that things are going well number two, maintain those daily habits like brushing and flossing, you know daily not skipping every couple days, but really trying to be religious about it. And number three I would say, doing those habit well. It’s kind of difficult to know how to floss the proper way. But doing so makes all the difference, or how to impress the proper way. But that really could be the difference between kind of getting caries under control versus continually every couple years still having another cavity and another cavity.

[email protected]: Thank you.

[email protected]: And then we have another question, “What our dentist trained regarding talking to the patient about their eating disorder and their behavior? So many of them that I've spoken to feel very uncomfortable addressing the eating disorder?”

Brittany Davis: Yeah, so the unfortunate news is that we don't receive much training at all regarding that sort of discussion. Which is why we see in practice, you know, dentists feel pretty uncomfortable. It is a difficult conversation, particularly when you get into the matter of maybe speaking to a minor. You know how do you do that when with their parents involved it's tough, but I think as dental professionals, it also is you know our responsibility to take on some tough and not so nice conversations.

Brittany Davis : So all that, to say the training in regards to how to have that conversation is pretty minimal as of right now but it's something that I, in particular, have my sights set on to try to make some sort of basic guidelines or just template and help us all ease into that.

[email protected]: Thank you.

[email protected]: Are there any additional questions? We've read all of the questions posed at this time. I'll give another minute or so, to see if there any additional questions from anyone else in the audience.

[email protected]: We have another question it seems, okay.

[email protected]: Can a dentist save a loose tooth?

Brittany Davis: Sure, it depends, it depends on why the tooth is loose, maybe for how long it's been loose, a whole bunch of different factors but, it being loose alone is not does not mean that there's no hope so, certainly there's a possibility. Without a doubt, it just depends on quite a few other factors.

[email protected]: Okay, great and um, thank you for that. There's an attendee stated that some of the eating disorder training for a dentist is done at The Alliance for Eating Disorders Awareness.

[email protected]: Okay Brittany, I'll give another minute again for any other questions at this time, but is there any additional research or information that you think is pertinent to the field of dentistry regarding eating disorders that you'd like to share with the audience?

Brittany Davis: So there's quite a bit of other information out there. I tried to present what is, kind of the most verified as of yet.

Brittany Davis: But there is a lot of less verified information that still requires more research before it can kind of be definitively said. So for example, there's still it's still up in the air, whether or not eating disorders do lead to higher rates of periodontitis or not that's a pretty large one that's up for debate still.

Brittany Davis: There are other symptoms, such as TMD, or temporal mandibular disorders, whether there's a significant correlation between those two potentially, I wouldn't be able to say for certain just yet.

Brittany Davis: And then that sort of one repeat, but with quite a number of other symptoms, so I guess all that to say is that eating disorders really affects our oral health far more extensively than we may realize and that just adds to and why it's so important for dentist to get involved in this space. And to you know really try our best to intervene early, to catch those that may have these symptoms, and refer them and get treated sooner than later, because it certainly has a pretty large impact on their oral and overall health.

[email protected]: Great. Thank you for that, we also had a few additional questions that came in, so the first one asked, eating disorders seem too often have a behavioral health component and as dentists, we tend to address the fixing aspect.

[email protected]: Acknowledging the movement of integrating oral health, behavioral health, and primary care level, the inter-professional organization that was mentioned at the beginning of your talk, can you share the name once again?

Brittany Davis: Oh, are you talking about the Academy for Eating Disorders?

[email protected]: I assume they said it was mentioned to be the inter-professional organization that was mentioned at the beginning of your talk, can you share the name once again?

Brittany Davis: Yeah so there's, there's several groups I’m working with that are trying to integrate oral health alongside the rest of medicine. So the Academy for Eating Disorders is one. There’s also one called the National Dental Association that has this inter-professional sort of just group that we have going on, where we're speaking with dentists, physicians, speech pathologists is kind of like a small sort of new group, we have going through that—like a new initiative. That just began it be a couple years ago.

[email protected]: Also, Brittany I’m the one that's mentioned in your bio, the Inter- professional National Dental Association, I think, may be another one that they're referencing yeah.

[email protected]: The next question is charcoal black toothpaste versus regular toothpaste, um the debate.

Brittany Davis: The age old question. So I’m going to say, I'm a fan of regular toothpaste. Only because the charcoal toothpaste, not to say that maybe just every once in a while using it is okay um you know, because it will brush off some stains, but it can be a bit abrasive. So using as a regular toothpaste can really take a toll on the enamel, so I would say don't make it your daily driver, but every once in a while shouldn't hurt, but I personally stick to regular toothpaste.

[email protected]: Thank you.

[email protected]: The next question asks, having treated many dental phobic patients, along with those with eating disorders in my past, I wish I had other health professionals available to work within a private practice setting to take a whole patient approach. Do you have any feedback regarding that?

Brittany Davis: It's so, it's difficult, dental phobic patients.

Brittany Davis: You know I really, I really feel for them, and I feel like it makes a lot of sense to be afraid of the dentist you know. You're working in such an intimate space, very close to what could be a stranger, maybe you're already in pain and you're worried that what they're going to do to you is going to cause more pain I think.

Brittany Davis: So I certainly think that having other health professionals, all together, to help would be the ideal, but I guess in the here and now, when it's normally just one on one it really just comes down to being very slow and patient with these you know, with these types of patients and maybe just setting.

Brittany Davis: Small goals, from the beginning. Maybe not even having a goal of treating something the very first visit, but just kind of talking and hearing out why they're afraid and what can be done to make them a little bit less afraid. Just you know, trying to regain their trust and not judging them for their fear.

[email protected]: Great, thank you for that Brittney.

[email protected]: The next person stated, FYI Columbia University was one of only three institutions that started in this interprofessional space back in the 1980s, with a program called Health of the Public Grant. Great presentation Brittany, I don't know if you want to expound a little bit on the Health of the Public Grant and what you know about it.

Brittany Davis: You know, I will say I don't know about it, but it looks like I've got some homework to do tonight, so I do appreciate that you brought that up.

[email protected]: Thank you.

[email protected]: That seems to conclude any questions that we have at this time. Once again, Brittany, I don't know if there's anything else that you may want to share with the group in terms of maybe additional articles that they might want to look up information regarding eating disorders within the field of dentistry, or any one of the references that you might want to have them focus a little bit more on, I'll give you that opportunity at this time.

Brittany Davis: So there are, there aren't handful that I would love to pass out. Will there be any opportunity to kind of send out in like a mass email in a few articles? I have some that aren't listed on this reference sheet that I would like to put together and distribute for those who like to read a little bit more.

[email protected]: Yes, there is an opportunity for us to send out references and the PowerPoint presentation in a mass email to everyone. We can collate all those documents and get everything together, send out on Monday, but they will receive the evaluation today.

Brittany Davis : Okay.

Brittany Davis: So then, I'll go ahead and put together some of my best articles and have everybody look out for that email. Ones that are kind of most up to date, easiest to read, most comprehensive, I'll go ahead and put together some of my favorites.

[email protected]: Okay um and just to reiterate everyone on Monday, we will be sending you additional references from today's presentation and a full copy of the slides from today. You will receive the evaluation to be completed via email once we conclude today's presentation.

[email protected]: I know some people would like to follow-up with Brittany separately for additional information and talk her information will be provided in the email that will be sent on Monday for you to contact her regarding any additional information that you would like to receive from her.

[email protected]: And if there aren't any additional questions, we will go ahead and conclude the webinar at this time. Thank you so much Brittany we truly appreciate your time and your expertise with sharing the information today, and thank you to all of our attendees for being able to attend this webinar and receive the information shared from Miss Davis.

[email protected]: Everyone enjoy your evening. Thank you once again from NCEED.

Brittany Davis : Thank you all for tuning in.