EATING DISORDERS AND ITS DENTAL IMPACT

Guided by-Dr.Rathika rai HOD,Dr Vijay Anand

Authors-C.Prakash,V.Sandhya,K.Selvarathi
Dept of prosthodontics,Thaimoogambigai dental college and hospital,
Chennai ,Tamilnadu.

ABSTRACT
This article is a review of eating disorders and its impact in oral tissues and their
management. As in most cases dentist are the first to diagnose eating disorders
as it may cause many changes in oral cavity and its function.Most commonly
affected people are teen girls and adult females.It is classified as Anorexia
nervosa, Bulimia nervosa, Binge eating disorder and pica.Most of these eating
disorders are associated with pyschological problem such as depression, anxiety
and obsessive complusive disorder.Dentist can contact psycharist to help the
patient medically and dental management are given by dentist.Most of the
patients are nutrionally challenged.Thus dentist also play an important role in
identifying and helping patients with eating disorder.
KEY WORDS-Eating disorder,oral cavity

INTRODUCTION
Eating disorders (ED) have psycho pathological causes and patient show abnormal
diet patterns; manifesting through deformed or chaotic eating behaviors (Lo
Russo et al., 2008)[1]. It leads to unhealthy lifestyle by destroying individuals
physical and emotional well-being[1]. Health issues like diabetes, loss of menses,
heart problem, self-esteem problems, metabolic and endocrine disturbances[2].
In addition to systemic problems, there may be some dental problems like
increased dental trauma, caries, xerostomia, dental erosion, salivary gland
swelling, and periodontal diseases[2]. It has increased incidence in both male and
female over past years and its mortality and morbidity rates are highest among
any mental disorders[3]. The dentist role in screening and diagnosis of such
systemic diseases by their oral presentation is well established[1]. The earliest
manifestation appears in oral cavity with an oral aesthetics deterioration,
discomfort, pain and impairment of oral functions with these dentists can
encounter this disorder[1]. Thus, dentist take care of their patient on regular basis
sometimes throughout their childhood and adolescences[3].
Disorders are present in many different forms and yet physical manifestation are
tip of iceberg when compared to side effects. Even with treatment some may
relapse and recovery is difficult[7].
Dental surgeons have an important role in finding such a patient by taking
detailed history and noticing oral changes, so that, he can communicate possible
findings to the psychiatrist and manage it properly with both psychiatric and
dental care as needed[4].

ETIOLOGY
The main cause for disorder is due unaccepted self perception and not satisfied
with one’s own body appearance. The eating disorder is also stimulated by
following factors like biological, psychological and cultural factor [1]. Media
portraying about unrealistic beauty and thinness about models affects the female
mindset. It usually occurs in females who have undergone physical or
psychological trauma and other illness like depression, anxiety, self injuring
personality, obsessive compulsive disorder, and chemical dependency [5]. Some
may have inherited it genetically, studies shows first degree relatives of patients
with eating disorder have 10 folds higher risk [6].
Biological factors include gene expression altered by environmental factors
without altering underlying DNA sequences. Eating behaviour is controlled by the
hypothalamus –pituitary-adrenal axis. Disturbances in hormone production,
transmission or its transmitters lead to eating disorders. Other conditions like
brain calcifications, elevated auto-antibodies, metabolic disorders and lesions of
frontal and temporal lobe [1]. Serotonin not only regulates appetite, but also in
mood regulation and hence several studies confirm that alteration in serotonin
activity leads to eating disorders [8].
Psychological factors like body image disturbance, personality traits, childhood
sexual abuse. Body image disturbances such as body cachexia that depends on
self esteem dissatisfaction. Personality traits like attention seeking, stress
reactivity, harm avoidance, perfectionism [8]. Due to poor self esteem and poor
self regulation these patients overcome this by altering their diet [1].
The Diagnostic and Statistical manual classified Eating disorder as Anorexia
nervosa(AN), Bulimia Nervosa(BN) and Eating disorders not otherwise
specified(EDNOS). The International Classification of Diseases (ICD) classifies into
AN, BN, atypical AN and BN, Vomiting interlinked with other psychological
conditions and psychogenic loss of appetite [9]. Here in this article lets discuss
about Anorexia Nervosa, Bulimia Nervosa, Binge Eating disorder, Picca, Night
Eating eating disorder.

ANOREXIA NERVOSA
Anorexia nervosa is a greek word, which means “loss of appetite”[13].It is
cautious self starvation and resulting weightloss linked with pathological fear of
gaining weight[10]. According to DSM -5,there are 3 diagnostic criteria
1)Inadequate calorie intake relative to need leading to a low body weight in
context of age , sex, development trajectory and physical health. Refusal to
maintain body weight irrespective to their age and height[10].
2)fear of gaining weight despite of underweight[10].
3)A damaged view of their own body weight,size and shape. And also lack self
evaluation and recognition of being low body weight and its serious issues[10].
Patient usually have amenorrhea[5]. They also use overexercise to burn
caloriesand mirror gazing always. Purging practices includes inducing
vomiting,useof laxatives,diuretics and slimming, medicines.[12].Anorexia patient
usually give history of low libido[13].
The risk factors are
Physiological /physical
change in cerebral functioning and serotonin.
Psychological /psychiatric
Depression or anxiety or any disorders in family or individual.
Obsessive compulsive disorder
Perfectionism
Environmental
Diet history .
Premorbid obesity .
Stressful life .
Any type of abuse.
Strong attitude to be thin always.[11]
It can be a coping mechanism against family conflicts, abuse or academic
pressure.[12]. Symptoms like lanugos hair covering the face and trunk, less BMI,
bradycardia,hypotension,bluish discolouration of feet and hand, hypothermia,
loss of heart and brain tissue, osteoporosis[10]. It may be sometimes mistaken as
depression disorder,schizophrenia, bulimia nervosa[13].

BULLIMIA NERVOSA
According to DSM-IV, it is defined as a episodes of binge eating that occur twice
weekly for 3 months or longer[6].
The patient usually has habit of self inducing vomiting with fingers or pencil or
comb to trigger the gag reflex, this leads to callus on dorsal side of the finger.
They should have proper dental checkup since the acid content of vomit often
erodes tooth enamel[13].Similar to anorexia these patients also misuse laxatives
and other medications. They indulge themselves in alcohol, drugs and tobacco
and sexual activities. There are two subtypes as purging type and non purging
type[13].
According to DSM 5 diagnostic criteria includes
1) consuming unusual amount of food in separate time interval.
2) Lack of control to overeating during an episode.
3) Compensatory behaviors like over exercising and burning calorie for that
uncontrolled overeating mainly during episodes over 3 months or longer
4) Always concern about body shape and weight.
5) Distrubances does not occur exclusively during episodes of anorexia.[10]
The weight of these patients usually fluctuates, but it is always within limits.
About one third of patient have a history of anorexia or obesity. The bulimic
patient usually consumes 1500-6000 calorie with hour of binge, usually high
calorie sweetened foods. Egg ice cream, sweets etc.. This is followed by an
episode of depression, guilt and purging behavior. According to research by the
National Institute of Dental and craniofacial in US, 28% of patients are identified
during the first dental appointments[5]. The risk factors include
Physiological/physical
Serotonin disorders.
Psychological/psychiatric
Personality disorder.
History of anxiety or depression or any other disorders in family or individual.
Having low self esteem.
Environmental
History of dieting.
Premorbidity overweight (18-40%). (7-20%)
Desire to be thin.
Any abuses.[11]
Medical complication like a sore throat, esophageal tear, dehydration, electrolyte
imbalance, irregular heartbeat, cardiac arrest, damage to liver, bowl, and kidney,
acne, alopecia, hypertrichosis[5].
They are mistaken as anorexia nervosa, neurologic disease, borderline personality
disorder,seasonal affective disorder and major depressive disorder[13].

BINGE EATING DISORDER

Large amount of food is consumed during short period of time. There is no
regular meal plan and timing and patient eat alone because of embarrassment of
eating more. Mostly these symptoms are also seen in bulimia nervosa[14].The
main complaint of patient with binge eating is weight gain. Most commonly seen
in a patient who is obese[15].
According to DSM 5, the diagnostic criteria are
1) Patient eats large amount of food in a short period of time in repeated
episodes.
2) There is no control about quantity of eating.
3) a. Eating very fast
b. Eating until they are uncomfortably full
c. Eating large quantities even not hungry.
d. Eating alone because of embarrassment.
e. Feeling depressed and guilt because of overeating
4. Occurs at least once a week for three months.
5. No compensatory.[10]
It results because of difficulty in reward processing and inhibitory
control[15].Binge eating occurs due to the negative effect in life which relieved by
eating. Some neuroimaging studies have indicated over activity of the
orbitofrontal cortex and low activity of prefrontal network in patient with binge
eating disorder. It is also associated with substance abuse, low moods and they
may have moderate to severe depression with BN[11]. These patients have
increased risk of diabetes, heart diseases, certain cancers and increased risk of
arthritis[5].

PICA
The name PICA is from Latin magpie which means bird known for big and random
appetite. It is a habit of eating non food substances like eating chalk, paper,
stones or bricks. Calcium, zinc or iron deficiency can be reason for pica. Unusual
consumption like clay may bind to iron and can cause deficiencies [17]. Most
commonly seen in children and low intellectual person and also seen in women
during pregnancy[16].
It is usually isolated disorder, but usually accompanied by OCD, schizophrenia
and trichotillomania[16]. Geophagia, pagophagia, amylophagia are some
complications. Lead poisoning complications seen in women during pregnancy
and high levels lead to seizure. Fetal toxicity has been reported [16].
MEDICAL COMPLICATIONS
Eating disorders always have a great impact over systemic health due to
malnutrition.[1]
ANOREXIA NERVOSA
It is a psychiatric disorder causing sudden death due to obstructive
coronary artery disease, left ventricular atrophy.Bradycardia due to sudden
weight loss and at times with spontaneous pneumothorax. The most common
effect on bone is that the osteoporosis .Most people commonly suffer from
hypoglycemia leading to osmotic dieresis. Sometimes utmost complications is
infertility. In some conditions dermatological changes like alopecia and increase
in facial hair with lots of wrinkles.[19]
Effect on Female
Females most commonly suffer from amenorrhea and 95% of females
suffer from psychiatric illness. Some woman suffer from euthyroid syndrome[6[.
BULIMIA NERVOSA
The condition usually occur due to self induced vomiting undergone by
some people for weight loss. The level of complication mainly occurs on the basis
of mode and frequency of vomiting due to electrolyte acid base balance. People
undergoing weight loss by self induced emesis often starve.[1]
Complications include alopecia,xerosis,pruritis and some people have sub
conjunctival hemorrhage due to lack of proper nutrition to the body.some people
insert their hand into their mouth to induce vomiting and cause skin aberrations
on hand. Most common complication of self induced vomiting is that the ulcers,
hemetemesis,Boerhaave’s syndrome. Dehydration is the other most commonest
complications of repeated vomiting leading to tachycardia, hypotension. It also
leads to increased risk of miscarriages. Emetic toxicity leads to sudden death at
times.Pneumodiastinum is another most causing complications due to aspiration
of food that is regurgitated.[2]
LAXATIVE ABUSE
Usage of laxatives causes effects like hypovolemia, functional
impairment, melanosis coli. Cathartic colon syndrome is another serious colon
syndrome resulting incapable of releasing feces.[2]

ORAL COMPLICATIONS
Loss of enamel and dentin(Perimolysis) is the most commonest
complication leading to sensitivity. Secondly comes the xerostomia due to
enlargement of salivary gland(sialadenosis).Impairment of taste(Dysgeusia) due
to xerostomia leading to redness of mucosa causing burning sensation and
bleeding gums leading to gingivitis, Periodontitis thereby increasing the risk of
dental caries and also causing opportunistic infections like candidiasis ultimately
leading to squamous cell carcinoma.[1]

Periodontal tissues
Periodontal disease is of two types – gingivitis and periodontitis.
Gingivitis is more common in anorexia patients because of poor oral hygiene.(6)
Periodontitis in an eating disorder patient is not an inflammatory condition, it is
because of deficient anti-bacterial host-defence mechanism.(9) The cause of
periodontitis in eating disorder patient is vitamin C deficiency and xerostomia.(6)

Oral mucosa
Lesions in oral mucosa are common in eating disorder patients. (9) The
aetiological factors are iron deficiency, vitamin B12 deficiency and self-inflicted
injuries.(9) Angular cheilitis, glossitis and mucosal ulceration are seen as a result
of nutritional deficiency.(4) Traumatic injuries are seen in soft palate of bulimic
patients when they try to induce vomiting using pen, finger, comb.(6)

Salivary gland
 Sialadenosis is one of the rare feature of eating disorder patients.(9)
Parotid gland is commonly affected.(9) Bulimia nervosa patients has more
chances of developing sialadenosis.(9) Sialadenosis occurs more commonly
patients who purge by vomiting.(9) Recurrent vomiting because of cholinergic or
autonomic stimulation is the cause of sialadenosis.(6) Salivary flow rate is
decreased in patients with eating disorder.(9) It results in increased incidence of
caries, more prone to infection and altered taste sensation.(9) Stimulated salivary
flow is reduced in eating disorder patients and unstimulated salivary flow is
reduced in eating disorder patients along with sialadenosis.(9) The pH of saliva is
decreased in anorexia nervosa and bulimic patients which predispose to dental
caries.(9)

Oral function
Eating disorder affects the normal chewing, swallowing and speech.(9)
The pharyngeal and velar gag reflex is absent in bulimic patient.(9) Bulimic
patients also experience abnormal swallowing pattern and altered taste
sensation.(9)

TREATMENT
MEDICAL MANAGEMENT
In anorexia, the patient recovery usually takes average of six years from
diagnosis. Patient is hospitalized and removed from all visitors, television and
independent use of washroom. It can be allowed as positive reinforcement after
weight gain. Psychotherapy and antidepressants is sometimes given for both
bulimia and anorexic patient (12). Medicine used for binge eating disorders can
include selective serotonin reuptake inhibitor (SSRI) like sertraline fluoxetine,
antiepileptic drugs like citalopram(15). In pica,the patient is given proper
education and interprofessional team approach by doctors is needed(16).

DENTAL MANAGEMENT
 If a patient is suspected to have eating disorder, the dentist should
ask questions regarding their food habits and check for any oral findings.(6)
Regular follow up should be done.(5)Patient should be advised to brush with
fluoridated tooth paste, and reduce acidic drinks and sweet consumption.(11)
Dental hypersensitivity and erosion is prevented by topical fluoride application.(6)
Patient is advised to rinse with water, milk or bicarbonate solution after vomiting
to neutralize the acidic environment.(11) Patient should be advised not to brush
after vomiting which may erode the tooth surface.(6) Salivary substitutes should
be given to counter xerostomia.(11) Composite resin restoration is done in
eroded tooth surface to prevent sensitivity.(11) Porcelain, metal onlays, veneers
are other options for composite restoration(5). Secondary prevention of eroded
tooth surface is done by giving mouth guards to the patients.(4)

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