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Home , Acid erosion, Binge eating disorder

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By Linda Douglas, RDH, Caring for dental patients BSc, a British dental hygienist based in with eating Ontario, Canada This article has the following disorders learning objectives: 1. describe the oral, psychological and systemic complications of eating disorders 2. recognise the warning signs of eating disorders 3. describe an evidence- based dental care and support protocol for patients with eating disorders 4. increased awareness of resources for individuals with eating disorders.

Introduction Several years ago, a concerned patient confided in me that her teenaged daughter was recovering from an , and she asked me to be vigilant for oral signs of relapse. Of course I readily agreed; as a dental hygienist, I was in an ideal position to detect oral signs of eating disorders. On reflection, however, I found that my knowledge of these signs was limited, and according to the 2005 research by DeBate, Tedesco and Kerschbaum,1 I was not alone in this predicament. I was aware of one classic sign - dental erosion related to the purging by seen in bulimia - and I could recognise some oral signs of malnutrition, but soon realised there were gaps in my knowledge. I was also uncomfortable with broaching this sensitive topic with a patient if an eating disorder was suspected. However, I understood my ethical obligation to increase my knowledge and participate in secondary prevention of eating disorders, as it could improve prognosis and even be a life-saver: eating disorders have the highest mortality rate of all psychiatric illnesses.2 My mission was to improve the care and support for my young patient, and others who might need it, by acquiring further knowledge of the oral and systemic signs of eating disorders. I needed the capability to initiate timely interventions, and minimise

©KatarzynaBialasiewicz/iStockphoto/Thinkstock damage to the oral hard and soft tissues. It was

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463-468) P roduced withpermissionfrom patient (from incisorsinthis the lingualsideof themaxillary R disorder (bingeing without purging). (starvation) and binge-eatingnervosa, (binge-purge),, anorexia disorder. women aged 15-24years had an eating According to a2002survey, 1.5%of Canadian Prevalence ofeatingdisorders substances, and various phobias. food to eat; getting up multiple times during night the hoursthe for normally reserved sleep-often compulsive, excessive intake of during food consumed; with quantity the and quality of food the dysmorphia; detrimental to health; exercising to point the where it becomes athletica, insulin inorder toweight; lose individuals intentionally insufficient take (EDNOS). and eating disorders specified not otherwise a clinically diagnosed eatinga clinically diagnosed disorder. suggest that one in100British women has eating disorders inEurope: recent figures eflux from vomiting led to acidicdissolution of There are variations of disorderedeating, by vomiting...’ pica d 6 which is obsessive, is excessive which The UKthehas highest rate of ue to purging ue topurging 4 , the persistent, the eating of non-food These include These , syndrome, eating night BDJ orthorexia nervosa, 2014; bigorexia 216: diabulimia D 463-468) r S . Weinstein anorexia , or muscle an obsession obsession an the the , 3 5 7 where where In In female bulimic(from A (from 35-year-old woman withanorexia andbulimia E been knownbeen to consume as much as 60,000 calories within one or two hours, but have usually consume 1,500to 3,000 between . of history ofhistory anorexia and some nervosa, have a limits. About one third of bulimics have a tends to fluctuate, but withinis usually normal exercise. The weight of individualsbulimic (not eating for at least 24hours) or excessive emetics, or other behaviours such as fasting vomiting, abuse of , diuretics, or include purging through self-induced behaviours to control one’s weight. These (binge-eating) and recurrent inappropriate consumption of massive amounts of food disorder and is characterised by apattern of is most the commonBulimia nervosa eating Bulimia nervosa over 50. children as young and as seven, inpeople aged 15-25 years of age, inmales, in but occur also Eating disorders mostly infemales occur aged months; some bulimic individuals vomit five at weekly least over twice of several aperiod a compulsion to purge. occur episodes These followed by , panic and guilt, and to consume quickly, like icecream. This is eat which are foods sweet, high-calorie easy calories inone bulimic binge.typically They common chronic illness among adolescents. USA,anorexiathe is third the most nervosa rosive andabrasive lesionsontheteeth ofa bizarre palatal haematoma ina30-year-old During bingeing,During bulimic individuals BDJ 2014; 216: www.nature.com/BDJTeam 463-468) BDJ 1999; 186: 109-113) 8

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or six times per day. Most bulimics who die Table 1 Medical complications of eating disorders13,14 do so in the act of purging. According to the General Heart and major organs National Institute of Dental and Craniofacial ■ ■ Research in the US, 28% of patients with Fatigue Cardiac arrhythmias, and cardiac bulimia are first diagnosed during a ■ dehydration, malnutrition arrest related to electrolyte imbalance (especially low potassium), dental appointment. ■ electrolyte imbalance dehydration, or starvation-induced ■ Hypoglycaemia atrophy of the cardiac muscle ■ Anaemia ■ Slow pulse rate Anorexia nervosa is marked by four ■ low white blood cell count, and ■ main features: low blood pressure impaired immunity ■ A refusal to eat enough to maintain body ■ impaired capacity to think, due to ■ slow metabolism weight within 15% of the minimally normal starvation-related brain changes ■ weight for age and height: the anorectic Osteoporosis ■ Kidney damage ■ individual is often 20% to 40% below a loss of muscle mass - causing ‘stick- ■ liver damage due to starvation of healthy body weight like’ limbs substance abuse16 ■ An extreme fear of gaining weight Skin ■ Hypothyroidism ■ ■ A distorted body image: thinking they are extremely dry, scaly, itchy skin with a ■ infertility related to disruption or 15 fat, even when they are emaciated grey cast cessation of the menstrual cycle ■ Amenorrhoea (absence of menstruation). ■ decreased scalp hair, which is short and brittle A significant number of anorectic ■ Increased lanugo hair - fine hair on individuals also purge, and some have pica; the back, abdomen and arms (the for example, consuming cotton balls soaked body’s attempt to retain body heat in orange to control hunger. The main after excessive loss of body fat) difference between bulimia nervosa and ■ Bloodshot eyes and broken capillaries purging anorexia is that the individual with (petechiae) of the skin around the anorexia is . eyes, related to forced vomiting

Digestive system Extremities Binge-eating disorder ■ abdominal pain ■ Clubbed fingers related to cardiac This is characterised by frequent consumption ■ complications, or overuse of laxatives of abnormally large amounts of food in one Chronic constipation ■ sitting, while feeling a loss of control over their ■ poor muscle tone of the colon, and Cold hands and feet related to peripheral vasoconstruction eating. Individuals with this disorder do not incontinence related to misuse of ■ purge afterwards, but feel depressed and guilty laxatives Russell’s sign: callouses, scars or abrasions on the knuckles of the after . Most individuals with binge- ■ ruptured oesophagus, or Mallory- dominant hand, related to inserting eating disorder are obese, with the related Weiss lesions (gastro-oesphageal the fingers in the mouth to induce increased risks of , heart disease, laceration syndrome) - bleeding, lacerated oesophagus due to vomiting certain cancers, and arthritis. vomiting ■ Carotenoderma-orange pigmentation ■ of skin, especially on the palms of the Aetiology gastric bleeding hands, related to a restricted with ■ ruptured stomach might occur during The aetiology of eating disorders is excessive intake of foods containing bingeing multifactorial, and not completely understood: carotene contributing factors include a culture where ■ liver damage due to starvation or thinness is admired. There are unrealistic substance abuse16 depictions of beauty and thinness in the ■ swollen parotid glands and sore media; at about 6 feet tall and 117 pounds, throat related to purging today’s fashion model weighs 23% less than the average woman. Some over-achieving Table 2 Psychological aspects of eating disorders17 perfectionists who do not fit this questionable ■ ■ ideal develop eating disorders: they have low depression, obsessive thoughts about food, calories and weight - often weighing self-esteem, a distorted perception of body ■ perfectionist, over-achiever oneself several times a day shape, and a poor body image.9 ■ low self-esteem ■ secrecy and denial of their illness: The risk of a female developing anorexia ■ Mood swings individuals with anorexia nervosa nervosa increases 10-20 times if she has a ■ guilt, shame often dress to hide their , sibling with the disorder. Eating disorders ■ alienation, loneliness and they might put coins in their often occur in individuals who have suffered ■ pockets when being weighed 10 social isolation physical or psychological trauma, and are ■ ■ eating alone they often claim to have food allergies frequently accompanied by other psychiatric in order to justify their restrictive diet illnesses11 such as depression, anxiety,12 self- ■ Compulsive behaviours harm (such as cutting), obsessive-compulsive ■ Misperception of hunger and satiation disorder, and chemical dependency. www.nature.com/BDJTeam BDJ Team 18 FEATURE

The medical complications of eating hypersensitivity is also common, and loss of is needed, plus comprehensive documentation disorders are shown in Table 1 and the bone density increases the risk of jaw fracture that includes detailed clinical notes, psychological aspects of eating disorders in during extractions. periodontal charting, radiographs, Table 2. intraoral photographs and study models to Medical treatment19 monitor damage. Oral findings Medical treatment of eating disorders often When an eating disorder is suspected, Traumatic lesions on the palate and includes nutritional therapy to address this sensitive topic needs to be broached in a oropharynx are caused by insertion of objects the medical complications, and also the non-judgmental, non-threatening manner. It to induce vomiting. Signs of nutritional starvation-related brain changes that is beyond our scope of practice to diagnose deficiencies occur, such as angular , perpetuate the condition. This is combined eating disorders, but we can present the candidiasis, , and oral mucosal with and , such as findings of our examination to the patient.22 ulceration. Individuals with eating disorders . For example, if there is dental erosion, also experience a dry mouth related to mention some possible causes: acidic drinks, dehydration, or xerogenic such Dental management of patients with acid reflux or frequent vomiting. This gives as antidepressants, and anxiolytics. They eating disorders20,21 the patient an opportunity for disclosure. have a high caries risk related to dry mouth These individuals need regular dental visits If they disclose their eating disorder to us, and impaired salivary buffering capacity, for continuing care and support, and we they should be referred to their physician; if and bulimics tend to consume foods high in should provide an environment in which the they are not ready to tell us, we can still be refined carbohydrates. In addition, individuals patient feels comfortable. Patients with eating supportive and initiate a prevention protocol with eating disorders often consume acidic disorders must be regarded as medically based on our clinical findings. drinks like citrus and carbonated compromised, due to the risk of grave Definitive dental restorations such as diet drinks. medical complications, particularly cardiac crowns cannot be completed while a patient is Dental erosion occurs due to purging by arrhythmias or cardiac arrest due to electrolyte purging regularly, as acid erosion will shorten vomiting18 and becomes apparent about six imbalance. the life of the restorations. Only essential restorative work should be done, sufficient to ‘We should be tactfully observant of their limit tooth damage and keep the patient free of pain. Pending recovery from their eating disorder, the dental hygienist can provide general demeanor...’ Thorough clinical assessment interventions to limit damage to the oral hard General appraisal begins as soon as we greet and soft tissues, and relieve and months after onset. Vomit has a pH of about our patient. We should be tactfully observant dental hypersensitivity. 3.8; during purging, the vomit hits the palatal of their general demeanor, gait, and facial During dental hygiene appointments, aspects of the maxillary anterior teeth. This symmetry; the skin should also be observed polish with a non-abrasive fluoride paste. A erosion eventually undermines the palatal for lesions and pallor, and the hands for protocol to reduce caries risk should include surfaces and leads to incisal fractures and Russell’s sign, or nail clubbing (for an example, in-office fluoride varnish applications, plus chipping, and overeruption of the mandibular see http://commons.wikimedia.org/wiki/ self-applied neutral fluoride, and calcium teeth. Erosion also occurs in the posterior File:Clubbing2.JPG). and phosphate products such as Novamin, teeth, causing perimylolysis - the tooth tissue A comprehensive medical history is needed, Recaldent, or nano-hydroxyapatite, to surrounding restorations is eroded, leaving and monitoring of the blood pressure and the promote remineralisation and relieve dental the restorations with a raised, island-like pulse. hypersensitivity. appearance. Eroded occlusal contacts also Extra-oral examination and intra-oral Xylitol products are also beneficial. When lead to loss of vertical dimension. Dental examination of the oral hard and soft tissues used for five minutes, five times per day, xylitol stimulates salivary flow, reduces the oral population of cariogenic bacteria, and reduces oral acidity. There are toothpastes, gum and candies containing xylitol. The patient should brush three times per day with a soft brush, and a toothpaste containing 5000 ppm fluoride. They need to clean interproximally daily, and also clean their tongue, to remove biofilm and acid residue. A mouthguard can be used to protect the dentition during vomiting. The patient should not brush directly after vomiting, as this causes more loss of tooth structure, and rinsing with water will reduce the protective properties of the . Instead, the oral pH should be Callus on the back of the hand (Russell’s An example of bilateral parotid enlargement; sign) in a 37-year-old male with a history of this is episodic (from BDJ 1999; 186: 109-113) neutralised by rinsing with one teaspoon bulimia nervosa of 20 years’ duration (from of bicarbonate of soda in 8 oz of water, or a BDJ 1999; 186: 109-113) product with calcium and phosphate ions. For

19 BDJ Team www.nature.com/BDJTeam FEATURE

additional support, as dental hygienists we resources/outside-support/ education/ce321/ce321.pdf (accessed January 2015). can also share information about resources for anorexia & bulimia care. Information and 21. Kaweckyj N. Eating disorders...understanding the dental ramifications. dentalcare.com. Available at: http://media. 23 those with eating disorders. statistics. http://www.anorexiabulimiacare. dentalcare.com/media/en-US/education/ce314/ce314.pdf org.uk/information-and-statistics-media (accessed January 2015). Conclusion 22. Perno Goldie M. Striving for thin. Dimensions 1. DeBate R D, Tedesco L A, Kerschbaum W E. Knowledge of Dental Hygiene. Available at: http://www. Eight years after that worried mother took of oral and physical manifestations of anorexia and dimensionsofdentalhygiene.com/Print.aspx?id=207 me into her confidence, her daughter is bulimia nervosa among dentists and dental hygienists. J (accessed January 2015). healthy. 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Symptoms of electrolytes raise the risk of cardiac over how much you eat? depression and anxiety in anorexia nervosa: links with plasma tryptophan and serotonin metabolism. arrhythmias ■ Have you recently lost more than Psychoneuroendocrinology 2014; 39: 170-178. B. they are at risk for osteoporosis, and One stone in a three-month period? 18. Hermont A P, Oliveira P A, Martins C C, Paiva S M, jaw fracture during extractions ■ Pordeus I A, Auad S M. Tooth erosion and eating do you believe yourself to be Fat disorders: a systematic review and meta-analysis. PLoS C. they are at risk for gastric bleeding when others say you are too thin? One 2014; 9: e111123. D. all of the above 19. University of Washington School of . Treating ■ Would you say that ood dominates F patients with mild-moderate special needs online course. your life? Fact sheets for dental professionals. Available at: http:// The correct answers will be published in the dental.washington.edu/continuing-dental-education/ February online issue of BDJ Team *One point for every ‘yes’; a score of online-courses/oc1401/ (accessed January 2015). 20. Stegeman C A, Slim L H. Recognizing and managing ≥2 indicates a likely case of anorexia eating disorders in dental patients. dentalcare.com. nervosa or bulimia Available at: http://www.dentalcare.com/media/en-US/ bdjteam20159 www.nature.com/BDJTeam BDJ Team 20