Understanding Eating Disorders — and How Dental Providers Can Help

Eating Disorders and Oral Health

During Mental Health Awareness Month in May, the number of articles, stories, and reports about mental illnesses increases. Organizations work to raise awareness, reduce stigmas, and provide myriad resources to support individuals and families and advocate for better access to care.

Few headlines, however, focus on the connection between mental health and oral health.

Research on the relationship between the mouth and the mind is limited, but it is growing. For example, in 2022, a survey by CareQuest Institute found that:

• Individuals with severe depression are more than twice as likely to report not brushing their teeth at least twice per day compared to those without depression.
• Those with minimal levels of depression also had more than twice the odds of reporting at least one oral health problem than those without depression.
• Adults who reported poor mental health were three times more likely to rate their oral health as poor.

Awareness of these and other issues — such as eating disorders — can help oral health providers provide whole-person care.

Eating disorders play a unique and significant role in oral health, as changes to the mouth are often the first warning signs of a larger issue. That means oral health professionals are often in a prime position to identify many eating disorders that could otherwise go unnoticed. Considering eating disorders have among the highest mortality rates of all mental health disorders, early detection and intervention can help save someone’s life.

Oral Health Indicators for Three Eating Disorders

Eating disorders are among the most lethal of the mental illnesses, second only to overdoses associated with opioid addiction. Several forms of eating disorders exist, including anorexia nervosa, bulimia nervosa, and binge-eating disorder — all of which have negative effects on the mouth. In fact, changes to the mouth are often the first physical indication of an eating disorder.

Individuals with eating disorders have greater than eight times the risk of experiencing tooth decay than individuals who don’t experience disordered eating. Given approximately 9% of the United States population, or 28.8 million Americans, will experience an eating disorder in their lifetime, it is important to increase awareness of eating disorders as an oral health issue. Below, we’ll explore the background and indicators of three common disorders:

1. Anorexia Nervosa

Anorexia nervosa is a type of eating disorder that often involves the fear of gaining weight. Though likely very thin or extremely underweight, individuals with anorexia nervosa still perceive themselves as large or overweight. Many try to achieve the “perfect body” through starvation or excessive exercise. Given the bidirectional relationship between oral health and diet and nutrition, poor nutrition will negatively impact a person’s teeth and gums. Restricting one’s food consumption can lead to a deficiency of calcium, iron, vitamin D, and other important nutrients critical for dental health.

Oral health indicators of anorexia nervosa include:

• Tooth decay
• Mouth sores
• Red/swollen gums
• Bad breath
• Dry mouth
• Cracked/dry lips

2. Bulimia Nervosa

Though similar to anorexia in terms of calorie restriction, bulimia nervosa differs in that it includes periods of binge eating, or overeating, several times a week or even several times a day that individuals often try to hide from people around them. In these binging periods, the individual often feels out of control of their eating and can consume up to thousands of calories in one sitting. Following this high calorie intake, the individual will force themselves to vomit or misuse laxatives or enemas in effort to expel the calories that were just consumed. Often this cycle is referred to as “binging and purging.” Patients who self-induce vomiting are 5.5 times more likely to experience dental erosion compared to patients who do not. The effects of bulimia on the oral cavity allow oral health professionals to identify signs of bulimia, potentially before other health professionals.

Oral health indicators of bulimia nervosa include:

• Erosion of tooth enamel
• Changes in tooth color, shape, and length
• Erosive mucosal lesions
• Redness, scratches, and cuts inside mouth
• Damage to soft palate
• Cuts or bruises on the knuckles from inducing vomiting
• Thin and brittle teeth
• Exposure of tooth pulp
• Arthritis in the temporomandibular joint or other temporomandibular joint disorders (TMD)

3. Binge-Eating Disorder

Binge-eating disorder occurs when an individual overeats but does not purge their bodies of the excess food. Rather, feelings of guilt often cause the individual to overeat once again. Repeated binge eating can increase the risk of tooth decay, the most common sign of binge-eating disorder. Often, individuals who overeat consume large amounts of foods that are high in sugar and acidic, while low in nutritional value. Frequent consumption of foods high in sugar increases the amount of time teeth are exposed to the dissolving effects of various acids, which then induces decay of the teeth. Therefore, those challenged by binge-eating disorder face higher risk of dental caries than those without this disorder.

Discussing and Treating Eating Disorders

Eating disorders involve significant disturbance of one’s eating behavior, whether it be extreme under- or over-eating. Many serious health complications can arise from eating disorders, and it important for patients to understand that these challenges can be addressed through proper medical and psychological therapy. In a nonconfrontational manner, dental professionals can bring oral signs that are consistent with eating disorders to the patient’s attention.

The University of Washington School of Dentistry has developed a helpful oral health fact sheet about eating disorders for dental professionals.

When discussing an eating disorder with a patient:

• Use nonjudgmental and nonthreatening communication while discussing suspicion of an eating disorder.
• Choose an appropriate time and location. Providers should make sure ample time to discuss concerns is allocated, and no other patients are nearby to ensure the patient privacy and comfort.
• Begin the conversation by calmly and slowly communicating the oral changes you have observed and the possible causes of these changes that indicate a potential eating disorder.
• Communicate with the patient about body image and eating habits if the patient invites and allows the conversation.
• Be aware of community resources for referral if patient is open to help. In a supportive and calm manner, encourage and support the patient in seeking professional help.

When helping to treat and prevent effects of eating disorders:

• Monitor patients’ dental erosion and mucosal lesions in regular checkups.
• Minimally utilize abrasive materials in dental treatment.
• Advise patients to avoid brushing their teeth within one hour after vomiting. Instead, they should rinse their mouth with water to reduce the amount of acidity and tooth erosion. Brushing their teeth in a weakened state due to the presence of gastric acid can cause more enamel damage.
• Educate patients about healthy eating habits and avoiding acidic foods and beverages.
• Consider making patients custom-made trays with 1.1% neutral fluoride gel to be used 5 minutes a day to increase remineralization of tooth enamel.
• Encourage chewing sugarless gum with xylitol, particularly for individuals with bulimia nervosa, to promote salivary flow.
• Encourage the use of palliative measures such as mouthguards to protect teeth from acid or buffering agents like antacids following self-induced vomiting.
• Check in with patient at every dental appointment regarding medical and recovery updates, as well as medication updates.
• Discuss referral possibilities with patient, such as a physician, therapist, or nutritionist.