DENTAL PROBLEMS RELATED WITH EATING DISORDERS
Eating is an important part of life. We need to eat to live, to grow and develop the way we should. But for some people food becomes the enemy as they are worried about being fat. They severely limit what they eat or make themselves vomit right after eating. Doing this can make someone very sick and people can even die of eating disorders.
Why then, would anyone do it? There isn’t just one answer!
What is Eating Disorder ?
These are primarily psychological conditions, often with severe medical complications and share the core features of self evaluation and weight perception and desire to be thinner.
Various Eating Disorders
Anorexia Nervosa
- Binge eating/Purging type
- Restricting type
Bulimia Nervosa
- Purging type
- Nonpurging type
Eating Disorder Not Otherwise Specified:
- Binge eating Disorders
According to International Classification of Diseases
- Anorexia Nervosa (AN)
- Bulimia Nervosa (BN)
- Atypical AN
- Atypical BN
- Vomiting ass. With other Psychological conditions
- Psychogenic Cause of Appetite
Other types are:
- Pica
- Prader-Willi Syndrome
- Night eating Syndrome
- Rumination disorder
- Body Dysmorphic disorder
- Orthorexia Nervosa
- Bigorexia
Biology of Eating Disorders
EDs are not due to the failure of will or behavior, rather they are real treatable medical illnesses in which certain mal-adaptive patterns of eating take on a life of their own.
1. ANOREXIA NERVOSA
What is Anorexia Nervosa?
It is an eating disorder of life-threatening proportion, characterized by relentless pursuit of losing weight, intense fear of becoming fat and delusional disturbance of body image.
It is characterized by extreme aversion to food, behaviors directed toward losing weight, and intense fear of gaining weight.
Prevalence
Rarely occurs in women above 40 years of age.
More than 90% in females.
Rare among males.
mortality rate is 10%.
Physical symptoms
ü Heightened sensitivity to cold
ü Gastrointestinal symptoms-constipation, fullness after eating.
ü Dizziness and syncope
ü Amenorrhoea (in females not taking an oral contraceptive), infertility.
ü Poor sleep with early morning wakening
Physical signs
ü Emaciation; stunted growth and failure of breast development.
ü Dry skin; fine downy hair (lanugo) on the back, forearms, and side of the face
ü In patients with hypercarotenaemia, orange discolouration of the skin of the palms and soles
ü Swelling of parotid and submandibular glands (especially in bulimic patients)
ü Cold hands and feet; hypothermia
ü Bradycardia, orthostatic hypotension, cardiac arrhythmias, dependent oedema
ü Weak muscles
Associated Features and Disorders
Depressed mood, Social Withdrawal, Irritability, Insomnia, Concern about eating in public, Feeling of ineffectiveness, Inflexible thinking
2. BULIMIA NERVOSA
Term Bulimia has been derived from the Greek for the word meaning Ox hunger, depicting extreme nature of binge eating.
Definition:
Bulimia nervosa is a severe, life-threatening disorder characterized by recurrent episodes of binge eating followed by self-induced vomiting or other purging methods (e.g., laxatives, diuretics, excessive exercise, fasting) to prevent weight gain.
Prevalence:
School population – 1% to 16%
College population – 1% to 13%
Community Samples – 1% to 13%
Adolescent and Young Women – 1% to 3%
Among males – 1/10th of that in females.
An individual struggling with bulimia is intensely afraid of gaining weight and exhibits persistent dissatisfaction with his body and appearance, as well as a significant distortion in the perception of the size or shape of his body.
3. BINGE EATING DISORDER (BED)
Binge eating disorder is a severe, life-threatening disorder characterized by recurrent episodes of compulsive overeating or binge eating. In binge eating disorder, the purging to prevent weight gain that is characteristic of bulimia nervosa is absent.
Binge eating is defined as eating more food than most people would eat in a short period of time (such as 2 hours), while feeling a lack of control over eating.
Prevalence:
Begins in late adolescence or early adult life.
Women are 1.5 times more likely to have BED than men.
Medical Complications:
Overweight, type 2 diabetes, high blood pressure, high blood cholesterol levels gallbladder disease, heart disease, certain types of cancer, Depression.
4. PICA
The word pica comes from the Latin word for magpie, a bird known for its large and indiscriminate appetite. As many as 25% to 30% of kids have an eating disorder called pica, which is characterized by persistent and compulsive cravings.
Pica is defined as a compulsive craving for eating, chewing or licking non-food items or foods containing no nutrition. These can include such things as chalk, plaster, paint chips, baking soda, starch, glue, rust, ice, coffee grounds, and cigarette ashes. Seen in young children and pregnant women.
5. PRADER-WILLI SYNDROME (PWS)
Is a chromosomal microdeletion disorder arising from deletion or disruption of genes in the proximal arm of chromosome 15. It affects 1:12,000-15,000 live births and it is found in both genders and all races, Major characteristics are hypotonia, hyperphagia, cognitive impairment, difficult behaviors and hypogonadism.
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Dental problems may include soft enamel, thick viscous saliva, poor oral hygiene, bruxism,
and rampant caries
6. NIGHT EATING SYNDROME:
It characterized by decreased appetite during the day and increased appetite at night , feeling tense, anxious, worried, or guilty while eating and have a tendency to eat carbohydrate-rich foods such as sugars and starchy foods.
In contrast to binge eating disorder, which is characterized by short intense bursts of eating, NES sufferers generally eat continuously throughout the evening and night.
7. BIGOREXIA:
It is a condition that has recently been observed as the “Opposite of Anorexia”.Found typically in body-building circles and known as muscle dysmorphia. Sufferers are more likely to take other risks with their health such as using steroids or body building drugs.
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8. ORTHOREXIA NERVOSA:
It is a condition that has been observed as an extreme pattern of dietary purity criteria.
It is an obsession with a pure diet, where it interferes with a person’s life.
9. ATYPICAL ANOREXIA AND BULIMIA NERVOSA
All criteria for Anorexia Nervosa are met except that, in females, regular menses are present, and despite significant weight loss, the individual’s current weight is in the normal range.
All criteria for Bulimia Nervosa are met except that bingeing and consequent inappropriate compensatory behaviors occur less than twice a week or for duration of less than 3 months.
EATING DISORDERS AND ORAL HEALTH
Dentists are considered to be one of the first health care providers who may come into contact with eating disorder patients.
Tooth Erosion
Most common and dramatic oral manifestation of chronic regurgitation typical of eating disorders (perimylolysis). Tooth erosion takes minimally two years to become clinically apparent, most commonly seen on buccal and occlusal aspects of teeth.
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Generalised erosion may lead to:
- Proud restorations
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- Expose and damage dentin (pulp) resulting in hypersensitivity to chewing, brushing, temperature changes & occlusal changes such as anterior open bite and loss of vertical dimension.
Dental Caries
Rich cariogenic diet, poor oral hygiene, salivary disturbances, both salivary rate and salivary composition influence caries susceptibility.
Antidepressant medications act as Antisialagogues.
Presence and absence of vomiting also adds for caries.
Effect on Bone
Main interest in looking at bone lies in the link between periodontal disease and osteoporosis.
Eating disorder patients are certainly at risk of low peak bone mass which results in osteopenia.
Effect on periodontal and gingival tissues
Generalized gingival erythema are the result of combined xerostomia and nutritional deficiency, advanced periodontal diseases are rare .It has been suggested that avitaminosis C is an etiological factor in periodontal disease in eating disorder patients and poor oral hygiene is more common in anorectic than bulimic patients.
Effect on Oral Mucosa
Trauma to the mucosa, particularly pharynx and soft palate.
Angular Cheilitis due to nutritional deficiency and trauma.
Mucosal lesions induced by trauma are frequently secondarily infected by atrophic candida organism, erythematous areas.
Other oral manifestations include oral ulceration and glossitis.
Effect on Salivary Glands:
Sialadenosis, Parotid glands are predominantly affected with prevalence figure of 10-50% among bulimic patients. And seems to occur only who purge by vomitting not by other methods. The onset of swelling usually follows a binge purge episode by 2-6 days. Affected glands are usually soft to palpate and painless.
Necrotizing Sialometaplasia, and Xerostomia has been reports in patients who binge eat and induce vomiting.
Salivary composition:
- Bulimic patients have greater amylase levels in both resting and stimulated conditions 25-60% of BN patients have raised amylase levels.
- Decreased bicarbonate concentration
- Increased salivary viscosity
- Decreased dissolved Ca conc.
EDs and Oral Functions:
- Deglutition and Gustatory Impairment
- BN patients learn to inhibit all but the most forceful self-induced tactile pharyngeal stimulation.
- Abnormal oropharyngeal swallow.
- Increased duration of dry swallow.
- Taste Impairment.
How to Assess Eating Disorders??
Adequate History of the patient.
Associated Characteristics:
Preoccupation with food
Vomitting
Laxative and Diuretic use
Exercise pattern
Body-weight Distortion
Menstrual History
Sleep Patterns
Addictive Behaviours
Social and Family Functioning
Questionnaire Methods.
Bulimic Inventory Test, Edinburgh (BITE)
Eating Attitude Test (EAT)
Body Image Automatic Thoughts Questionnaire (BIATQ)
Body Image Assessment (BIA)
Mirror Exposure Distress
Private Body Talk Questionnaire (PBTQ)
Eating Habit Questionnaire (EHQ)
Prevention of Eating Disorders
Dental Management:
Medical History
Emergency Care
Preventive Care
î Daily fluoride rinses
î Custom trays for fluoride application
î Alkaline mouth rinse
î Soft brush, circular brushing, floss daily
î Sugar free mints, chewing gum
î Place temporary restorations.
î Reduce intake of acidic drinks
î Prescribe neutral artificial saliva
Restorative Care
Psychopharmacological Management
Anorexia Nervosa
îNeuroleptics- Chlorpromazine, Pimozide, Sulpiride.
î Antidepressants- Fluoxetine, Clomipramine.
î Other Drugs- Cyprohepatidine, Lithium Carbonate.
Bulimia Nervosa
î Antidepressants- TCAs, Fluoxetine, Trazodone, Bupropione.
î Other drugs- Lithium, Anticonvulsants, Opiate Antagonists, and Fenfluramine.
Binge Eating Disorder- Antidepressants
Non-Pharmacological Management
Cognitive Behavioral Approach
î Psychoeducation
î Self-monitoring
î Nutritional Counselling
î Cognitive-Behavioural Technique
Cognitive Analytical Therapy
Education and Behavior Therapy
Cognitive Behavior and Body Image Therapy:
- Relaxation technique
- Desensitization
- Training in self-monitoring
- Identification and monitoring of cognitive body image errors
- Self-assessment
- Use of multiple strategies to reduce compulsive patterns.
AUTHORS
Dr DARSHAN D.D.
Dept of Oral Medicine and Radiology.
