Oral Complications as a Consequence of Bulimia Nervosa and Anorexia Nervosa

Introduction

Eating disorders are a subgroup of psychiatric disorders that have significant consequences on the body. Eating disorders are characterized by a psychopathology fixated on eating behaviour, weight, shape, and the individual’s efforts at controlling them. Anorexia nervosa and bulimia nervosa are recognized as the two main types of eating disorders commonly found in adults. Anorexia nervosa (AN) is subdivided into two groups; restrictive type and purgative type. In regards to the restrictive type, weight loss occurs by reducing food intake, fasting, and excessive exercise. Furthermore, the purgative type is defined as the use of laxatives, diuretics, vomiting induction, and appetite suppressors. Bulimia nervosa (BN) is defined as recurrent episodes of binge eating. It can also be subdivided into restrictive or purgative type. The purgative aspect of BN and AN are where eating disorders begin to pose a major problem on the oral cavity. Complications as a result of purging could include; tooth decay, dental erosion, dental hypersensitivity, periodontal disease, xerostomia, etc. Therefore, I ask, are adults with anorexia nervosa and bulimia nervosa more likely to develop oral health issues, than adults who do not suffer from anorexia nervosa and bulimia nervosa?

Discussion of the Evidence

Each article shares similar conclusions that eating disorders pose a problem in regards to oral health. In addition, each article did share some differences in their findings, as each article studied different aspects of oral health.

In the European study, elevated salivary concentrations of ASAT and total protein were found in patients with ED’s, as well as an increase in xerostomia. In the Portuguese study, an association between a reduced salivary flow rate and a lower buffering capacity, lead to a lower salivary pH within the oral cavity. Both studies concluded that eating disorders can affect the biochemical composition of saliva, as well as salivary flow. However, the European study did not find a significant difference in buffering capacity between the ED group and control group. In regards to xerostomia, the British study further verified that vomiting and starvation could lead to hyposalivation and xerostomia. The European study mentioned they found the parotid gland to be enlarged in 31% of patients with an ED, but no findings of this in the control group. 

Secondly, DMFT and DMFS were both used in the British and Portuguese study to evaluate the client’s dentition. The British study found that patients with eating disorders had significantly more decayed, missing and filled surfaces than controls, as well as an increase in DMFT. The Portuguese study confirmed patients with eating disorders presented significantly increased DMFT, DMFS, and tooth decay scores compared to controls. 

Additionally, the British study found dental erosion was five times more likely to occur in patients with ED’s, than those without. Patients with self-induced vomiting had a higher likelihood of erosion at an odds ratio of 7.32. While those without vomiting had an odds ratio of 3.10. The Portuguese study also explained that patients in the eating disorder group showed significantly higher levels of dental erosion. This study also found a correlation between the severity of the erosion and dentin hypersensitivity. Both studies agreed that dental erosion occurs most often on the lingual surfaces of the dentition. Due to the fact that these surfaces are left unprotected by the tongue and soft tissue during purging episodes. The American article, was the only article that touched on perimylolysis, a smooth erosion of the tooth enamel, which results as a loss of enamel and dentin on the lingual surfaces of the dentition, caused by frequent vomiting. 

Moreover, the British study explained that poor dental health can have major consequences for patients with eating disorders which include impairment, pain, and discomfort. In the Brazilian study, groups B and C (Group B- Anorexia nervosa purging subtype, Group C- Bulimia nervosa), had the highest complaints of frequent facial pain. Group B measured 52.6% and Group C measured 56.3%, these results were significant in comparison to the control group. The Brazilian study was also able to find that reduced salivary flow could interfere with swallowing and cause increased strain of the infrahyoid muscles and digastric muscle. In addition to this study, there was a higher prevalence of masticatory myofascial pain and complaints of pain in patients with eating disorders, in comparison to healthy counterparts. 

Conclusion

Each study concluded that patients with anorexia nervosa and bulimia nervosa experienced more oral health issues, in comparison to healthy patients. Each article agreed that reduced salivary flow/ xerostomia, were shown to be more prevalent in patients with eating disorders. The European study was the only study that went in depth on the biochemical composition of saliva in patients with eating disorders. While the Brazilian study was the only one who correlated reduced salivary flow to pain. Each article was able to cover the significance of eating disorders on oral complications such as dental erosion, decay, pain, xerostomia, etc. Each article was relevant as the authors had either dental and medical backgrounds. The articles were also peer-reviewed, credible, and published within the last 5 years. Some weaknesses within the evidence were small sample sizes and gender distribution. The Portuguese study only conducted research on women. While the European study conducted research on 50 women and 4 men. Therefore, for the research to be more reliable they should improve upon sample size, gender distribution, and monitor the effects of eating disorders on the oral cavity for longer periods of time. 

Implications for Practice

In practice oral health care professionals may notice the signs and symptoms of an eating disorder present in a client. A screening question asking the client if they have any trouble with eating or maintaining weight is recommended. It is important to be non-confrontational with the client, and bring any oral issues to their attention. The client may not admit to having an eating disorder when asked. It is fundamental to ask subsequent questions at each appointment, and provide appropriate referrals. The clinician should also provide the client with oral hygiene instruction to try to subdue the effects the ED has had on the oral cavity. It may also be important to educate the client on the serious complications an eating disorder can have on the body. The clinician should always approach the situation gently, and not confront the client. 

Implications for Education

Educating members and students in dentistry is imperative, as they may be the first professionals to encounter these clients. They may be the first people to start a conversation with the client on their eating disorder. It takes multiple medical professionals to care for someone with an ED, and a dental personnel may be the first to provide treatment and appropriate referrals. Eating disorders can be fatal, and signs and symptoms should not be taken lightly. That is why it is important that we are able to recognize these signs, because by recognizing you could be potentially saving their life. 

Implications for Research

I believe that each study has areas they can improve upon for further research. Firstly, I believe that sample size should be increased. This way a more positive correlation can be found between patients with eating disorders and those without. As previously stated, I feel they should conduct research that studies equal parts men and women. The studies could also improve on the type of questionnaire they use to assess the patient's eating disorder. Conducting the research over longer periods of time may also yield more data to be analyzed. In conclusion, I think that further assessing the client’s medical history, for example, how long they have had the ED, may also yield more accurate results.

Implications to Personal Practice

Lastly, in my own practice I will look for the signs and symptoms of an ED on a client. I know now how important it is to acknowledge these signs and provide the proper guidance to the client. I will address the client in a non-confrontational manner, and gently guide them on the path that will provide them with the most appropriate care. I will also go over proper oral hygiene with the client to prevent any further oral complications.

Summary

In synopsis, each study and article was able to detect a positive correlation between eating disorders, specifically AN and BN, with oral complications. Each study focused on different aspects of oral health, but there was plenty of overlap to further answer my PICO question. It was proven that patients with eating disorders suffer from an increase in oral complications such as xerostomia, dental erosion, pain, decay, impairment, etc, in comparison to their healthy counterparts. It is important that dental health care professionals are able to recognize the signs both clinically and during medical history. Eating disorders have a high mortality rate, and providing clients with the help they need, even if it is just a referral, can make a huge difference. Anorexia nervosa and bulimia nervosa are systemic diseases that can wreak havoc on oral health. With further research we can find the best ways to treat client’s suffering from this silent disease, and provide them with the proper guidance and treatment. 

References

• Souza SP, Antequerdds R, Aratangy EW, Siqueira SRDT, Cordás TA, Siqueira JTT. Pain and temporomandibular disorders in patients with eating disorders. Brazilian Oral Research [Internet]. 2018 Jan [cited 2019 Nov 10];32:1–8. Available from: http://search.ebscohost.com/login.aspx?direct=true&db=ddh&AN=135620543&site=ehost-live
• Johansson A, Norring C, Unell L, Johansson A. Eating disorders and biochemical composition of saliva: a retrospective matched case--control study. European Journal of Oral Sciences [Internet]. 2015 Jun [cited 2019 Oct 10];123(3):158–64. Available from: http://search.ebscohost.com/login.aspx?direct=true&db=ddh&AN=102674739&site=ehost-live
• Steinberg BJ. Medical and Dental Implications of Eating Disorders. Journal of Dental Hygiene [Internet]. 2014 Jun [cited 2019 Nov 10];88(3):156–9. Available from: http://search.ebscohost.com/login.aspx?direct=true&db=ddh&AN=96851641&site=ehost-live
• Lourenço M, Azevedo Á, Brandão I, Gomes PS. Orofacial manifestations in outpatients with anorexia nervosa and bulimia nervosa focusing on the vomiting behavior. Clinical Oral Investigations [Internet]. 2018 Jun [cited 2019 Oct 10];22(5):1915–22. Available from: http://search.ebscohost.com/login.aspx?direct=true&db=ddh&AN=129594697&site=ehost-live
• Kisely S, Baghaie H, Lalloo R, Johnson NW. Association between poor oral health and eating disorders: systematic review and meta-analysis [Internet]. The British journal of psychiatry : the journal of mental science. U.S. National Library of Medicine; 2015 [cited 2019Nov11]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26429686