Periodontal Impact of Anorexia Nervosa and Bulimia Nervosa

Dentists and dental hygienists may be the first healthcare providers to assess the physical and oral effects of anorexia and bulimia nervosa, making them ideal for early identification, referral, and treatment.

Dental issues can be manifested as early as six months following consistent disordered eating behaviors, such as calorie restriction and purging [1].

If oral complications go unidentified, it can lead to more serious issues and potentially irreversible damage to the oral cavity.

When doctors examine the mouth, face and general appearance of the patient, it can be a secondary prevention of an eating disorder.  Oral issues associated with anorexia and bulimia include erosion patterns in teeth, which are identified as “intra-oral”and “extra-oral” effects [2].

Common Dental Health Side Effects

“Intra-oral effects” include dental erosion, traumatized oral mucosal membranes and pharynx, dry mouth, cavities, periodontal disease, and soft tissue lesions. Loss of the enamel on the teeth or a notched appearance on the surface of the teeth, as well as loss of contour, are all common in those with AN and BN.   

With erosion also brings tooth sensitivity to hot and cold temperatures.  Induced vomiting can also cause trauma to the palate and pharynx in the mouth.  With bulimia nervosa, symptoms reported have been tooth erosion, tooth sensitivity, dry mouth, cavities, periodontal disease, enlarged glands, and poor oral hygiene.  

Both anorexia and bulimia share physical manifestations in regard to dryness of mouth and skin, arrhythmia, and cracked or dry nails. Medical issues can also manifest in the blood, cardiovascular, central nervous system, endocrine, gastrointestinal issues, musculoskeletal, renal, and liver function [2, 3].

Further extra-oral concerns have been lanugo, or growth of fine body hair, loss of head hair, weight changes, growth or lipoma on extremities, and erosion or inflammation of the fingernails if used to induce vomiting.

There seems to be a consensus in the literature of oral health among those with eating disorders that enamel erosion is the most common and dramatic manifestation of chronic vomiting. This typically allows dentists to make a differential diagnosis to distinguish an eating disorder from other causes.

The Effects of Oral Hygiene on Eating Disorders

With AN, there is typically a deficiency of nutrition, and that can cause the gums and tissue within the mouth to bleed more easily.  An individual may also see increased saliva, dry mouth, and swelling within the mouth.  

Nutrients that promote oral health include foods with calcium, iron and vitamin B which many with AN lack.  If an individual is not getting these proper nutrients, it can promote tooth decay and gum disease [3, 4].  Malnutrition can lead to sores inside the mouth, development of bad breath, and canker sores.  

Frequent vomiting can lead to strong stomach acid flowing over the teeth. The tooth’s enamel can be eroded and teeth can change in color, shape, and length. Often teeth become brittle, translucent, and weak. Excessive tooth brushing or rinsing in relation to purging behaviors can promote tooth decay [4].

Degenerative arthritis in the jaw is also a dental complication found with eating disorders. This is where the lower jaw hinges to the skull and, when arthritis begins, it can create pain, chronic headaches, and difficulty chewing, as well as difficulty opening and closing the mouth.

Purging behaviors can lead to redness, scratches, and cuts in the mouth, as well as cuts or bruises on the knuckles. Salivary glands are also enlarged with purging behaviors and occurs up to 50% in patients with eating disorders [5].

Poor oral hygiene seems to be more common with those with anorexia than bulimia, as higher plaque occurs and gingivitis may be more common. Research has shown that xerostomia and nutritional deficiencies may cause generalized gingival erythema [5].

Recovery is Possible

Treatment is possible to prevent further tooth decline and support your overall eating disorder recovery. Individuals are recommended to keep to a consistent hygiene routine and frequent dental follow-ups to prevent further destruction of tooth structure [4, 5].

Individuals in recovery might need to have regular professional dental care more often than every six months. Dentists can provide in-office topical fluoride applications to prevent further erosion and reduce sensitivity.

Individuals can do a daily application of sodium fluoride gel to promote remineralization of enamel and use of artificial saliva for patients with extreme dry mouth. Individuals can also rinse with water immediately after vomiting, followed by a sodium fluoride rinse to neutralize acids and protect teeth, in an effort to reduce dental damage in the early stages of recovery when full cessation of behaviors might not be possible.

If there is restorative or prosthodontic treatments needed, the individual needs to have ceased the eating disorder behaviors and be psychologically stable prior to dental treatment.  It is essential that individuals consult with their dentist prior to using any dental treatments.

In conclusion, early detection and intervention is key and dental practitioners are instrumental in the recovery process, as they are often the first health professionals to identify signs and symptoms of disordered eating. With proper dental care and treatment, proper oral health can be achieved in recovery from anorexia and bulimia nervosa. Being honest with your dental provider is an essential part of your treatment plan to address all symptoms related to the eating disorder.

 

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About the Author: Libby Lyons is a Licensed Clinical Social Worker and Certified Eating Disorder Specialist (CEDS). Libby has been practicing in the field of eating disorders, addictions, depression, anxiety and other comorbid issues in various agencies. Libby has previously worked as a contractor for the United States Air Force Domestic Violence Program, Saint Louis University Student Health and Counseling, Saint Louis Behavioral Medicine Institute Eating Disorders Program, and has been in Private Practice.
Libby currently works as a counselor at Fontbonne University and is a Adjunct Professor at Saint Louis University, and is a contributing author for Addiction Hope and Eating Disorder Hope. Libby lives in the St. Louis area with her husband and two daughters. She enjoys spending time with her family, running, and watching movies.

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References:

[1] Agras, S. (n.d.). The Consequences and Costs of the Eating Disorders.  Psychiatric Clinics of North America., 371-379. Retrieved April 30, 2017, from http://www.sciencedirect.com/science/article/pii/S0193953X0570232X
[2] DeBate, R., Tedeseco, L., & Kerschbaum, W. (2008). Knowledge of Oral and Physical Manifestations of Anorexia and Bulimia Nervosa Among Dentists and Dental Hygienists. Journal of Dental Education. . Retrieved April 30, 2017.
[3] Aranha, A.,  Eduardo, C., Cordas T.  (2008). Eating Disorders Part 1: Psychiatric Diagnosis and Dental Implications. Journal of Contemporary Dental Practice. Retrieved April 30, 2017.
[4] Retrieved April 30, 2017, from https://www.nationaleatingdisorders.org/dental-complications-eating-disorders
[5] Steinberg, B.( 2012).  Medical and Dental Implications of Eating Disorders. Journal of Dental Health.  Retrieved April 30, 2017, from  http://jdh.adha.org/content/88/3/156.full

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The opinions and views of our guest contributors are shared to provide a broad perspective of eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer discussion of various issues by different concerned individuals.

We at Eating Disorder Hope understand that eating disorders result from a combination of environmental and genetic factors. If you or a loved one are suffering from an eating disorder, please know that there is hope for you, and seek immediate professional help.

Published on May 16, 2017.
Reviewed By: Jacquelyn Ekern, MS, LPC on May 9, 2017.
Published on EatingDisorderHope.com