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 dentistry. 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 Anorexia Nervosa and 2% could be diagnosed with Bulimia Nervosa. 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 vomiting. 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 gastric acid 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.