By Jenny H. Conviser, PsyD, CEDS; Sheehan D. Fisher, PhD; and Rana Stino, DDS
Water Tower Dental Care, Chicago, Illinois
Northwestern University School of Medicine, Chicago, Illinois,
Feinberg School of Medicine, Chicago, Illinois
Reprinted from Eating Disorders Review
One of the key components of bulimia nervosa (BN) is episodes of binge eating, followed by compensatory behaviors such as purging. In addition to the mental health components of BN, serious medical and dental complications can result from purging behaviors.
Repetitive vomiting can lead to serious dental and oral health problems. Tooth erosion (perimylolysis), dry mouth (xerostomia), tooth sensitivity, dental caries, and gum (periodontal) disease are common intraoral manifestations that result from the deleterious effects of the vomit’s acidic gastric content. The saliva’s flow rate, pH level, buffering capacity, and enzyme content (e.g., pepsin, trypsin) after purging may damage soft tissues of the mouth and gums as well as tooth enamel. Enamel erosion is the most prevalent intraoral complication of purging. Although the frequency and duration of purging behavior influence the severity of enamel erosion, the effects can be moderated by the use of preventative oral hygiene practices.
Early detection may reduce damage
Early detection of signs of purging and implementation of recommended oral hygiene can be instrumental in reducing oral/dental damage. Several general preventive oral health behaviors can reduce erosion of enamel and protect oral health. These include rinsing the mouth daily with a 0.5% sodium fluoride solution or using a prescription 1.1 sodium fluoride toothpaste, flossing daily, brushing with a “soft” bristle toothbrush, increasing daily intake of water, promoting salivary flow through consumption of sugarless gum and mints, and limiting contact between surfaces of the teeth and reducing exposure to acidic foods (e.g., having the patient use a straw to drink acidic beverages, such as fruit juice or carbonated drinks). Another suggestion that may help reduce enamel damage is to have the patient rinse his or her mouth with water or an alkaline solution immediately after purging.
In contrast, some actions after purging can be harmful to the teeth and mouth. One surprisingly damaging practice is brushing one’s teeth immediately after purging (e.g., within less than an hour). Brushing with toothpaste and brushing alone may compound the damaging effect of stomach acids on tooth enamel and soft tissues of the mouth. Educating patients about such preventative oral health practices is essential, yet there are major communication barriers between oral health professionals and patients with BN.
Research on dentist-patient communication and eating disorders has primarily focused on secondary prevention practices in the dental care community. Secondary prevention of eating disorders includes identification of a disorder, direct communication with the patient, recommendations for preventive at-home oral care, referrals to treatment, and case management. Despite the importance of secondary prevention practices, DeBate and colleagues found that fewer than half of dentists and dental hygienists regularly assessed patients for oral manifestations of eating disorders and fewer than half of patients suspected of having an eating disorder were given pertinent dental care instructions by dentists and dental hygienists.1,2
Similarly, the fact that patients don’t ordinarily bring up the subject of eating disorders is also a major barrier to assessment and treatment. Willumsen and Graugaard found that only 43.8% of patients with BN disclosed their eating disorders to their dentist.3 Patients with BN may be hesitant to discuss their eating disorder ED because of ambivalence about recovery and feelings of shame. Barriers to patient-initiated communication may thus impede or complicate the dialogue about BN and prevent access to early intervention and treatment.
A Study of 201 Patients
In an effort to further understand post-purging practices and BN patients-oral health care professionals’ communication, we conducted a study of 201 women previously diagnosed with BN. The study, recently published in The Journal of the American Dental Association,4 showed that most women (92.4%) had at least one or more dental health problems that could be attributed to purging, including sensitive teeth, erosion of enamel, change in color, shape, or length of the teeth, tooth pain, oral lesions, caries, gum recession, and dry mouth. However, only about half of the women sought information about oral care to reduce damage to their teeth and mouth.
Most of the women reported that the “Internet” was the most helpful source of information about oral health. Most had also not discussed their eating disorder with their primary oral health professional, due to negative emotions (e.g., embarrassment, shame, fear), and women who did have a discussion with their provider were more likely to have initiated the conversation. Women with BN suggested that the best way to make it possible to discuss their eating disorder and to learn about oral health recommendations would be through having professionals: (1) obtain more education and training about eating disorders; (2) initiate the conversation more often; and (3) approach the topic of eating disorders with greater sensitivity.
What Dental Professionals Can Do
Dental health care providers are in a unique position to preserve and promote good health for patients with a history of eating disorders. To be most effective in this role, the following guidelines are recommended:
Improve knowledge and awareness of eating disorders. Dental professionals can improve their knowledge and awareness about eating disorders and related issues by joining professional organizations such as the National Eating Disorders Association (NEDA), Anorexia Nervosa and Associated Disorders (ANAD), the Academy of Eating Disorders (AED), the Binge Eating Disorder Association (BEDA), or the International Association of Eating Disorders Professionals (iaedp). Other helpful measures are attending conferences that include presentations on eating disorders and participating in professional eating disorders certification training programs and other educational opportunities, when available. Networking with eating disorders professionals may also be useful.
Provide information. Dental professionals should have general information on the assessment and treatment of eating disorders and provide guidelines for recommended post-purging oral care available in printed material or posted online. Patients may be interested in receiving printed literature or referral to website postings with information about local eating disorder treatment programs and support groups or informational links, such as: AED.org, NEDA.org, ANAD.org, and BEDAonline.com.
Refer patients for additional assessment. There is no need for the dental healthcare professional to formally diagnose an eating disorder. It is not beneficial to force the patient to “admit” the specifics of his or her purging history. Threats, lectures, reprimand, shaming, and blaming only make matters worse. Accurate information can improve patient awareness of the effects of the eating disorder-related behavior and help patients to more realistically consider the treatment options available to them. The patient may be referred to other eating disorder professionals for additional formal assessment if needed.
Revise patient health history questionnaires. Include questions about a history of eating disorders and post-purging practices on health history questionnaires that are completed by patients at the time of their appointments. Invite patients to discuss any history of an eating disorder and any concerns. You might ask, “Have you had any history of an eating disorder?”; “Have you ever engaged in purging or self-induced vomiting?”; and “Do you have any questions for the medical staff about EDs and your oral/dental health?” On printed materials or website advertising, remind patients that health care professionals in your office understand that EDs impact oral and dental health and that your medical staff subscribes to non-blaming, thoughtful and compassionate care for patients having ED history or behavior.
Adopt a nondiscriminatory treatment policy. Inform patients that health care providers are dedicated to treating and preserving patient health regardless of past health history.
Protect patient privacy. Discuss eating disorders matters in a private space, to protect the patient’s privacy. Inform the patient in advance of policies regarding release of information about eating disorders to other parties, including parents. Finally, be certain to ask the patient’s permission to pose questions or to discuss his or her history of an eating disorder. One example would be, “May I ask you about a history of purging?”
Initiate effective communication. Remain focused on the specific health conditions that you are observing and treating. State any clinical observations simply, briefly and directly. State that you care and are willing to listen. Encourage the patient’s participation in discussions about how to proceed. For example, you might say, “I am seeing some additional acid erosion today and I am concerned. In terms of eating disorders, I would like to hear how things have been going so we can work together to take good care of your health.” “Are you getting the treatment or support that you need for your eating disorder?” Or, you might say, “Thank you for sharing some information about your eating disorder history. I know this can be hard to talk about, but I have some ideas about how I can help. First, I would like to hear your thoughts or concerns.” Or, you might say, “In terms of purging and eating disorder behaviors, how have you been doing?” Any initial conversation that addresses the eating disorder thoughtfully and constructively can serve as a foundation for more open and constructive discussion in the future.
Offer collaborative care. Make referral information available in your office/clinic and on your website for local healthcare professionals (physicians, therapists, dietitians, and psychiatrists, etc.) with expertise in treating people with eating disorders and who are able to provide compassionate and competent care. Offer your willingness to speak with other health care providers to help support optimal care.
Encourage treatment adherence. The course of recovery from an eating disorder can be a long and challenging process, with much ebb and flow. Lapses do not mean failure. Longer-term professional treatment promotes recovery. Encourage the patient’s commitment to ongoing treatment and support.
Discussion and Conclusions
The lack of communication about eating disorders appears widespread within the dental health professional community. Additional study is needed to better understand if similar communication limitations exist in the larger healthcare community. The recommendations proposed here may be useful for both oral health professionals and other healthcare professionals who encounter women or men with BN or purging behaviors.
Dental visits provide a valuable opportunity to detect signs of eating disorder history and to support the patient’s recovery efforts. The dental care professional is in a pivotal position to provide accurate information about the health risks associated with eating disorders and to encourage early intervention and/or continued treatment. Healthcare professionals, who are able to initiate thoughtful communication with their patients about eating disorders, have the opportunity to improve treatment outcome, preserve good health and support eating disorder recovery.
About the Authors
Dr. Jenny H. Conviser is Assistant Professor, Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago. Sheehan D. Fisher, PhD, is an instructor at the Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, and Rana Stino, DDS, is a General Dentist at Water Tower Dental Care, Chicago.
- DeBate RD, Plichta SB, Tedesco LA, Kerschbaum WE. Integration of oral health care and mental health services: dental hygienists’ readiness and capacity for secondary prevention of eating disorders. J Behav Health Serv Res 2006; 33:113.
- DeBate RD, Vogel E, Tedesco LA, Neff JA. Sex differences among dentists regarding eating disorders and secondary prevention practices. JADA 2006; 137:773.
- Willumsen T, Graugaard PK. Dental fear, regularity of dental attendance and subjective evaluation of dental erosion in women with eating disorders. Eur J Oral Sci 2005; 113:297
- Conviser, JH, Fisher SD, Mitchell KB. Oral care behavior after purging in a sample of women with bulimia nervosa. JADA 2014; 145 (4):352-354.