Knowledge of oral and physical manifestations of anorexia and bulimia nervosa among dentists and dental hygienists

Despite the crucial role oral health care providers can have in the early identification of eating disorders and the referral and case management of patients with these disorders, little is known concerning their knowledge of oral complications of these disorders. The purpose of this study was to determine the knowledge among dentists and dental hygienists concerning the oral and physical manifestations of eating disorders. Employing a randomized cross-sectional study, data were collected from 576 dentists and dental hygienists randomly selected from the American Dental Association and the American Dental Hygienists' Association. Results indicated low scores concerning knowledge of oral cues, physical cues of anorexia, and physical cues of bulimia among study participants. More dental hygienists than dentists correctly identified oral manifestations of eating disorders (p=.001) and physical cues of anorexia (p=.010) and bulimia (p=.002). As the first health professional to identify oral symptoms of eating disorders, the most important task of the dental care provider when identifying oro-dental signs of eating disorders is to ensure that the patient receives treatment. Implications for education include the addition of conceptual, procedural, and skill-based curricula objectives addressing etiologic assessment and patient communication--thus increasing behavioral capacity for delivery of restorative care and patient referral.     

Dental wear as a stomatologic manifestation of bulimia nervosa--a clinical case

The number of patients with anorexia and bulimia nervosa is increasing nowadays. The typical oral feature of these eating disorders is the dental erosion which causes sensitivity of the teeth and esthetic problems for the involved patients. This phenomenon is a characteristic feature in these cases and it may be the first sign of the mentioned disorders. The purpose of the study was to describe the generally the most characteristic oral findings of bulimia nervosa and anorexia nervosa because the dentists play a significant role in recognizing the basic problem of the patients, and they can send them for medical treatment of the serious general problems.     

Eating disorder-induced dental complications: a case report

Eating disorders are potentially life threatening and have not lost their relatively poor prognosis in the last decades. Whereas the increase in incidence and prevalence rates of anorexia nervosa over time are questionable, an increasing trend in incidence and prevalence of bulimia nervosa has been reported. Dentists are often involved in treating teeth of patients with both anorexia nervosa and bulimia nervosa because the teeth of these patients are regularly affected by erosion and caries. Without identification of the underlying evidence of psychological problems and consequent treatment, a patient's medical and dental health will deteriorate as the eating disorder progresses. The dentition of the patient with an eating disorder may offer specific signs and characteristics to alert the dentist.     

Eating disorder patients. Recognition and intervention

The prevalence of eating disorders is increasing, as are the chances that one or more of your patients may be suffering from anorexia nervosa, bulimia nervosa, or a combination of these disorders (bulimarexia). Although the dental profession has focused attention on the related oral and dental pathoses that occur in this population, limited information is available in the area of intervention. Recognition of these individuals is only the first step. Should a patient be suspected of having any of these disorders, intervention is the next step, to actually link the patient to medical help. This paper reviews pertinent behavioral characteristics, medical complications, and the oral, dental, and physical manifestations of these disorders in order to aid the dental hygienist in the recognition of eating disorder patients. Guidelines for conducting interventions are provided and sources for referral identified.     

Saliva Changes in Pediatric Patients with Eating Disorders

ObjectivesTo determine the differences between pediatric patients with eating disorders (ED) and the control group in the amount of saliva and the concentration of total amylase and electrolytes in saliva, and to evaluate the correlation between the saliva changes and nutritional status.Material and methodsThe study included 101 participants (14.34 ±1.99 years), out of which 50 participants with ED subgroups and 51 participants in the control group. Data were statistically analyzed (Mann-Whitney, Kruskal-Wallis, chi-square, Spearman rank correlation test, α=0.05).ResultsNo significant differences in salivary volume between the groups were found. A significant difference in the volume of saliva secreted in the 5th and 15th minute was found between the anorexia nervosa and bulimia nervosa subgroups. The examined anthropometric parameters were marginally or significantly positively associated with saliva volume at 5 and 15 minutes, noting a more significant correlation of the same at 15 than at 5 minutes. The patients with ED had a significantly higher concentration of inorganic phosphates in saliva while the concentrations of other electrolytes and total amylase in saliva did not differ significantly.ConclusionsNutritional status affects salivation. There is a difference in saliva volume in pediatric patients with different ED disorders. Variations in saliva electrolytes in pediatric patients with ED are possible.     

Eating disorders in the female patient: pathophysiology and treatment strategies

Eating disorders are common in girls and women. Two common eating disorders--anorexia nervosa and bulimia nervosa--have significant medical complications. Oral and maxillofacial surgeons must be cognizant of the signs, symptoms, and medical consequences of these disorders. The increased incidence of these diseases has implications in the surgical management the oral and maxillofacial surgery patient. A review of the literature and guidelines in the perioperative management of these surgical patients are presented in this article.     

Eating disorders: identification and intervention

Society's preoccupation with outward appearance and thinness has increased the incidence of both anorexia nervosa and bulimia nervosa, two potentially threatening diseases. Unfortunately, it is difficult to obtain accurate statistics on these eating disorders. Those with an eating disorder are often unwilling to admit they have this disorder and are reluctant to seek help. Subsequently, eating disorders have become a serious concern for medical and dental professionals. Since dental professionals see patients on a regular basis, he/she may be the person to whom the eating disorder patient confides.1 For the same reason, the oral care provider may be the first to notice oral manifestations of disease in the anoretic or bulimic person.2,3 The dental professional can serve as an important link between the person with an eating disorder and professional therapy. Knowledge of the signs and symptoms for these diseases is important because early diagnosis and treatment can result in more successful therapy.     

Sex differences among dentists regarding eating disorders and secondary prevention practices

BACKGROUND: The purpose of this cross-sectional study was to assess sex differences among dentists pertaining to current behaviors and behavioral beliefs with regard to eating disorders. METHODS: The authors collected data via a self-administered paper-and-pencil questionnaire from a randomized sample of 350 practicing male and female dentists. RESULTS: The results showed a low level of practice regarding secondary prevention (that is, measures leading to early diagnosis and prompt intervention) of eating disorders. The authors found statistically significant differences, with more female than male dentists reporting that they assessed patients for oral cues (P < .001), more female dentists reporting that they provided specific dental care instructions (P = .038) and more female dentists referring patients who have oral signs of eating disorders (P = .028). They also found sex differences with regard to mediating factors. Female dentists had greater knowledge of oral manifestations of eating disorders (P = .001), greater knowledge of physical cues of anorexia nervosa (P < .001), greater perception of the severity of anorexia nervosa (P = .007) and greater knowledge of physical cues of bulimia nervosa (P < .001). CONCLUSIONS: Although the dentist may be the first health care provider to assess oral effects of eating disorders, his or her involvement may be influenced in part by sex and sex-related health beliefs. CLINICAL IMPLICATIONS: Female dentists may be more sensitive to oral cues related to women's health issues. Further research is warranted to explore the mediating factors regarding secondary prevention of eating disorders.     

Anorexia/bulimia-related sialadenosis of palatal minor salivary glands

In patients affected by alimentary disorders sialadenosis is frequently observed. This non-inflammatory condition is described to affect major salivary glands, leading to the characteristic parotid and/or submandibular swelling. Thus fine-needle aspiration cytology or parotid open biopsy are generally required to diagnose histologically the disorder. We report the case of a 28-year-old patient affected by bulimia/anorexia nervosa who presented, in addition to parotid enlargement, a bilateral symmetric painless soft swelling of the hard palate. The lesion was biopsied and histopathological examination showed the classical features of sialadenosis. To our knowledge, this is the first case of sialadenosis affecting palatal minor salivary glands. It underlines that when sialadenosis is clinically suspected, clinicians could check also patients' oral cavity for minor salivary glands involvement, in order to potentially avoid invasive extra-oral procedures and to easily confirm diagnosis with an intra-oral biopsy.     

Eating disorders in the oral health curriculum

Due to the oral/systemic nature of eating disorders, this serious health issue requires comprehensive patient assessment and coordinated health treatment. The purpose of this study was to assess the breadth and depth of eating disorder and comprehensive care within the dental and dental hygiene curriculum. Survey data were collected from deans of U.S. dental programs (n=24) and dental hygiene program directors (n=94). Statistically significant differences were observed between dental programs (DP) and dental hygiene programs (DHP) as more DHP reported including anorexia nervosa (p<.001), bulimia nervosa (p<.001), and oral manifestations of eating disorders (p=.003) within their curricula. Clock hours dedicated to these topics ranged from seventeen to thirty-five minutes, with no statistically significant differences observed between DP and DHP. Only 58 percent of DP and 56 percent of DHP included patient communication skills specific to eating disorders. Moreover, DHP were observed dedicating more instruction time for this skill (p=.011). As greater emphasis is placed on oral/systemic health and the provision of comprehensive care, many oral health professionals may not be adequately trained to identify, provide education, and communicate with patients regarding the oral/systemic nature of eating disorders. The findings from this study indicate that there is a need for appropriate training to better prepare oral health professionals for comprehensive patient care.     

Eating disorders: dental implications

This article presents updated information on the 2 major eating disorders, anorexia nervosa and bulimia nervosa. Both conditions are found primarily in women. The eating disorders have significant morbidity and mortality associated with them. Patients are vulnerable to sudden death from cardiac arrhythmias. Suicide is a concern in some patients. The etiology of the eating disorders is unknown, but genetic, cultural, and psychiatric factors appear to play a role. Medical management may involve hospitalization to stabilize the patient, behavior modification, drugs, and psychotherapy. The long-term outcome of treatment is unclear at this time. The role of the dentist as a "case finder" is discussed. Also, the role of the dentist in restoring the dental and oral tissues to a healthy state in patients with eating disorders is presented.     

Oral findings in anorexia nervosa and bulimia nervosa: a study of 47 cases

These two clinically oriented articles deal with problems dentists are seeing more frequently. One hospital dental service sees an average of four to five patients weekly with eating disorders. The first article is a research study discussing problems found in 47 study participants with the eating disorders anorexia nervosa and bulimia nervosa. The second article describes a helpful technique for oral rehabilitation.     

Increasing dentists' capacity for secondary prevention of eating disorders: identification of training, network, and professional contingencies

The incidence of eating disorders has increased substantially over the last forty years. Primary care physicians and dentists share a parallel challenge for secondary prevention of anorexia nervosa and bulimia nervosa. The dentist, in particular, has a uniquely important and valuable role with respect to assessment of oral and physical manifestations, patient communication, referral, case management, and restorative care. Despite this crucial role, few dentists are engaged in eating disorder-specific secondary prevention. The purpose of this study was to explore beliefs, attitudes, and experiences of general dentists regarding eating disorder-specific secondary prevention behaviors using focus group methodology. Three ninety-minute focus groups were conducted with twenty-one general dentists (seventeen male, four female) recruited from the 2004 Academy of General Dentistry Leadership Conference. Data from the focus groups were analyzed to identify two over-arching themes and associated subthemes with regard to supports and barriers to eating disorder-specific secondary prevention practices. Analysis of data revealed that training, network, and dental professional contingencies emerged as places of influence for increasing capacity among dentists with regard to secondary prevention of eating disorders. This exploratory assessment identifies leverage points where strategic interventions including curriculum development, policies, and practices can be developed to support and sustain secondary preventive clinical behaviors among dentists.     

Factors affecting the oral condition of patients with severe motor and intellectual disabilities

Background:  Handicapped persons living in nursing homes have special risks for oral diseases.
Objective:  To investigate the specific factors related to the occurrence of dental caries and tooth extraction in patients with severe motor and intellectual disabilities (PSMI) residing in an institution.
Methods:  One hundred eighty-nine PSMI residing in a single institution in Japan were followed for 3 years. Oral examinations were conducted at baseline and 3 years later. The following items were investigated: age of subject at admission, period of institutionalization, age at baseline oral examination, status of rumination, drooling, type of ward, dietary mode, and etiology of the impairment. Logistic regression analyses were conducted to examine factors associated with new dental caries and tooth extraction occurring during the study period.
Results:  By multivariate analysis, rumination and tube feeding were identified as significant factors associated with new dental caries. On the other hand, infancy or childhood impairment and drooling were identified as significant factors related to tooth extraction.
Conclusion:  Some specific factors in this patient population affect the dental caries and tooth extraction and oral programs targeting these factors may reduce dental degeneration in these patients.     

Eating disorders in women's oral health

Eating disorders such as anorexia nervosa, bulimia nervosa, and binge-eating disorder are a serious concern in women's oral health and a clinical challenge to dental professionals. Each of these eating disorders presents with unique patterns of psychologic, medical, and dental characteristics. Appropriate dental treatment is based in the multidisciplinary facets of these conditions. The dental team should be mindful that individuals who suffer from these disorders may relapse into previous negative eating behaviors. The knowledgeable dental professional may be able to intercept these habits through regular recall intervals and thorough examination.     

Access to special care dentistry, part 6. Special care dentistry services for young people

This article brings together some of the 'hidden disabilities' common amongst adolescents and young adults. Many of these conditions carry a social stigma and some are associated with secretive behaviour and even denial. The article will describe the features, management and oral implications of five eating disorders (Prader-Willi syndrome, anorexia nervosa, bulimia nervosa, binge eating disorder and pica) and three types of mental health problems (schizophrenia, obsessive-compulsive disorder and bipolar disorder). Without the input of the dental profession, and in the main the primary dental care service, all these conditions can have a detrimental effect on the dentition at a relatively early stage in life. Mental health problems are more common in adolescents and young adults than most people realise and this article will also consider the impact on oral health and delivery of dental care to young people who have experienced childhood sexual abuse.     

Review of linear epidermal nevus with oral mucosal involvement – series of five new cases

Introduction:  Linear epidermal nevi are sporadic hamartomatous alterations of the epidermis and superficial dermis that clinically appear as verrucous papules and plaques distributed in a linear pattern following Blaschko's lines. Their extent varies from unilateral involvement (nevus unius lateris) to extensive bilateral involvement (ichthyosis hystrix). Oral mucosal lesions have rarely been described.
Aims:  We review the literature, focusing on the rare intraoral manifestations of linear epidermal nevus.
Case series:  We present a series of five new cases with oral mucosal involvement. Four cases had associated cutaneous lesions and one case had oral lesions exclusively. Histopathologic evaluation of lesional tissue in four cases showed hyperkeratosis, acanthosis, epithelial hyperplasia, and papillomatosis. Dental abnormalities, consisting of enamel hypoplasia and congenitally missing teeth, were noted in one patient adjacent to the oral lesions.     

Onset and progression of clinical manifestations of orofacial granulomatosis

Background:  There remain few studies describing in detail the early occurrence and long-term progression of clinical manifestations of orofacial granulomatosis (OFG) in a substantial number of patients.
Objectives:  The aim of this study was to determine the early and late clinical manifestations of a large case series of patients with OFG.
Patients/methods:  Clinically relevant data of 49 patients with OFG who attended an Oral Medicine unit in the UK were examined retrospectively. The analyzed parameters included occurrence and typology of initial manifestations at onset and with respect to long-term follow-up.
Results:  Five major patterns of disease onset were observed. Recurrent facial swelling with/without intra-oral manifestations was the single most common presentation at onset followed by intra-oral ulcers, and other intra-oral and neurological manifestations. The majority of patients later developed a spectrum of additional features.
Conclusions:  OFG results in multiple manifestations at different time points. The disease onset is characterized by manifestations other than facial swelling in about half of affected individuals. However, patients can develop cosmetically unacceptable lip/facial swelling at a later stage. Nearly all affected individuals ultimately develop lip/facial swelling while about half of all patients develop oral ulceration.     

Salivary profile and oxidative stress in children and adolescents with cystic fibrosis

J Oral Pathol Med (2010) 39 : 16–21
Background:  Cystic fibrosis (CF) is characterized by altered exocrine secretions; however, no comprehensive compositional profile of CF serous and mucous saliva secretions has been published.
Design:  We analyzed salivary flow rate and composition, and oxidative stress-related parameters, comparing CF patients with non-CF bronchiectasis patients and the healthy controls.
Results:  Median salivary magnesium concentration and lactate dehydrogenase activity were significantly lower in CF patients than in the healthy controls. Salivary total protein concentration was 45% higher in CF patients than in non-CF bronchiectasis patients. CF patients showed 8% lower levels of peroxidase compared with non-CF bronchiectasis. Salivary total antioxidant status, superoxide dismutase and uric acid values in the CF group were higher by 15%, 35% and 31%, respectively, than in both control groups.
Conclusions:  Cystic fibrosis patients demonstrated altered salivary profile, especially in antioxidant enzymatic and molecular activity, possibly resulting from the oral cavity's ongoing inflammatory and oxidative process. Free radical mechanisms may be involved in CF pathogenesis.