By Lisa Dowst-Mayo, RDH, BSDH
As a dental hygiene educator, I have an interesting approach in teaching ergonomics to my first-year students. I tell them my plan is to turn them all into ballerinas, even the men! They think I'm kidding, but in reality, I'm not. If you think about it, many of the ergonomic concepts we learn in dental hygiene -- e.g., how to sit, where to place our knees and feet, how to keep our shoulders back, leaning forward from the hips, keeping our backs and spines in a straight line -- are many of the same body positions taught in basic ballet technique. One aspect of hygiene school I excelled in was posture, which was not surprising since I had 20 years of ballet experience!
By now, you all are thinking this article is going to be about ergonomics or maybe ballet technique. Well, I fooled you! This article will cover subject matter I have purposely avoided for many years -- the eating disorder anorexia nervosa. I have published numerous pieces for RDH over the past seven years, but I have always avoided this topic due to its personal nature for me. After 20 years of dancing ballet, you can imagine the number of girls I had close personal contact with who suffered from a variety of eating disorders. It's hard to see your friends suffer, and it brings back some not-so-fond memories for me. However, it is through experience and triumph over adversity that one learns the pearls of wisdom of life; and today, I am going to share my pearls about anorexia nervosa (AN).
I started dancing ballet at age 3 and gained so many wonderful personality attributes from years of studying ballet such as discipline, demeanor, a drive for excellence, balance, coordination, competition, and poise, just to name a few. Those qualities led me to have a successful career in college and now as a dental hygienist. However, one negative trait that can come from years of looking at your body in mirrors and being forced to have an "ideal body type" to get that "perfect" part, as one director told me, is that some ballerinas would take weight loss to an extreme. They would try to stay thin to get the part, to look like others in the class, and to impress directors at auditions, even if that meant practically starving themselves. The saddest part is they saw nothing wrong with their actions. To them, the end result justified the means. I am in no way saying every person who dances has an eating disorder. I am saying I encountered a few along my journey who did, and I want to share some of their stories with you so you may better understand anorexia nervosa.
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Being anorexic is not easy. I know that statement sounds crazy to most people, but it's really true. It takes discipline, a support system (enablers), control, and drive to sustain such a horrible disorder. I met a girl when I was 15 who was the same age as I and had an obvious eating disorder. She smoked for appetite suppression, used laxatives when she had to drop a couple of pounds before an audition, and learned how to hide all of this from her loved ones. Aside from our ballet classes, she would run one or two times per day regardless of being sick or overtired. She focused all her thoughts on what she did not eat that day and constantly weighed herself. She never hung out with us after dance class or had any hobbies. At one point she weighed just less than 100 pounds and was 5'11". If you asked her how she thought she looked, her answer was always the same, "fat with love handles." What she saw in the mirror was completely different than what others saw: a severely underweight and malnourished girl. This altered body image is what psychologists call body dysmorphia and is one of the four diagnostic criteria for AN. Body dysmorphia is when a person is excessively concerned with his or her body image and has a preoccupation with a perceived image or defect. Such people also tend to have negative emotions about the way their body looks.
I'll never forget my first year in dental hygiene school when we were taught a course on eating disorders. That was a very out-of-body experience for me since I spent my life around girls with these issues and never thought twice about it. I remember the professor discussing anorexia nervosa and talking about the distorted body image and distorted relationship these people have with food. I also remember not totally agreeing with her description. From what I noticed, those girls had no issues with food itself. To them, food was not the demon or the enemy; their personal/psychological issues were. See, I don't believe people with AN have any particular feeling or emotions toward food itself like obese or bulimic patients do. They gained no satisfaction or dissatisfaction from particular foods; it was the feeling of control and internal drive to accomplish this extremely difficult goal of starvation that seemed to give them that serotonin rush. My friend would only get frustrated to the point of tears when she "failed" in her own mind and decided to eat something. It was the failure -- not the food itself -- that gave her those feelings. As you read this next section, you will better understand why she felt the way she did.
The definition of anorexia is the lack or loss of appetite for food. This is drastically different than anorexia nervosa (AN), which is an eating disorder usually occurring in early to mid-adolescent females (90% to 95%) as opposed to males of the same age category. It is characterized by the refusal to maintain a normal minimal body weight, fear of gaining weight, disturbance of body image, undue reliance on body weight or shape for self-evaluation and self-esteem, and amenorrhea. There are many theories on the risks and causes of people developing AN -- such as environment, genetics, biological, or societal pressures -- and this article will present all those theories. There are two subtypes within the eating disorder of AN:
- Restricting type: People who eat only a couple hundred calories a day or maybe just drink water. The human body still gets hungry; these people have just learned to control their hunger and actions surrounding it.
- Binge-eating/purging type: People who starve themselves just like the restricting types but then give in to their hunger and may binge, eat a normal meal, or even just a cookie and make themselves vomit. Medically speaking, this is the most dangerous type.
People with AN have obsessions with food, weight control, eating, portioning of foods, and tend to only eat small amounts of food during one sitting. They will be fanatic about what sorts of food they choose to eat, often having monotonous choices in food and restricting whole food categories (particularly carbohydrates and fats). People with AN are obsessively concerned with the calorie and fat grams in food. I knew one ballerina who could list the total calorie and fat gram intake per serving of any food she would eat without looking at the box! It is common for them to deny their hunger because they are afraid of eating and gaining weight. They may have strange rituals with food and mealtimes. In fact, they will consistently give excuses as to why they need to miss mealtime situations. When they do eat, many will rearrange their food on their plate, eat certain foods in a particular order, and excessively chew their food. I had a close ballet friend who told me she did this to prolong her noneating time at the table so when the rest of the family was done with their meal, she would claim to be done as well and throw away any uneaten food before anyone saw what was left on the plate. By rearranging food on a plate, she could better identify and separate the less caloric food from the higher, which helped her feel more control of mealtime situations.
Some with anorexia nervosa may use laxatives, diuretics, or enemas, especially if they tend to binge eat. After a person with AN binge eats or eats too much according to his or her own theories of adequate food intake, this person may follow up with extreme dieting, vomiting, and excessive exercise; or a combination of those three with the use of the above listed pharmacologic substances. These people are also fanatics with exercise. They will follow extreme, intense, rigid exercise regimes despite injury, weather, fatigue, or illness. Some will smoke to help with appetite suppression and act as a stimulant when they are fatigued.
Table 1 lists the signs and symptoms of AN according to the National Institute of Mental Health. I divided the signs and symptoms into two categories: psychological and physiological.
Statistics of anorexia nervosa
AN affects 0.5% to 1% of American women and is the third most common psychiatric diagnosis in adolescents.6 Ninety-five percent of those with anorexia nervosa are between the ages of 12 and 25. Eighty-six percent report the onset of anorexia nervosa by age 20 and 43% report the onset of the disorder between the ages of 16 and 20.7
The mortality rate ranges between 5% and 20% and appears to be dependent on the length of time one has lived with the disorder. It has one of the highest death rates of any mental health condition. The death rate is 12 times higher than the death rates associated with all causes of death for females ages 15 to 24.8 Relapse is common and many will relapse multiple times before successful recovery. People with AN are typically resistant to treatment, which is understandable due to the ego-syntonic nature of the disorder as evident by their refusal to accept the seriousness of the medical consequences of their weight.3
People with AN tend to display certain personality traits, which appear in childhood, long before the onset of the disorder. These traits may put a person at a special vulnerability to developing AN. Perfectionism, obsessive-compulsiveness, neuroticism, negative emotionality, harm avoidance, low self-directedness, traits associated with avoidant personality disorder, high constraint and persistence, low novelty seeking (bulimics have high novelty-seeking), constriction of affect and emotional expressiveness, ahendonia (inability to experience pleasure from activities usually found enjoyable), and asceticism (lifestyle characterized by abstinence from various worldly pleasures), and reduced social spontaneity in restricting-type AN.3
Individuals with AN have an obsessive, perseverative, and rigid personality style. Those with AN do well with goal-directed behavior; however, they have difficulties with feedback from others and changing their behavior to better meet those goals. They often feel they should be able to do things perfectly without making mistakes, and they have little appreciation for the fact that mistakes are a normal part of the learning experience. For the restricting type of AN, they tend to adapt poorly to a changing environment but have an enhanced ability to pay attention to detail or use a logical/analytic approach.3
It is important to remember that these temperament and personality traits will persist after recovery from AN, which contributes to the high rates of relapse. Most health-care professionals note a minimum of a year is necessary for initial recovery from AN. Women who were long-term restricting-type AN tend to have a persistence of anxiety, perfectionism, and obsessional behaviors, which needs to be managed properly so relapse does not occur.
Think of the type of person you may see in your dental office who could be suffering in silence from AN based on the above description. It would be the high-achieving, motivated, good student, who always brushes and flosses properly because she is a rule-follower. These patients would be respectful, polite, quiet, and would get very upset if told they had a cavity because they are perfectionists; and a cavity means they did something wrong because a cavity is bad. Or at least that is the way they would interpret it.
The pathogenesis of AN is not well understood. Evidence suggests altered brain serotonin (5-HT) function contributes to dysregulation of appetite, mood, and impulse control.3 This altered serotonin function can persist after recovery. Because someone with AN typically has a dysphoric temperament/mood, restricting their food intake may become a powerful reward and provide them with temporary relief from their temperament.3 This contributes to a vicious cycle: by lowering caloric intake, they get relief from their mood fluctuations, but then malnutrition and weight loss produce alterations in neuropeptide and monoamine function (serotonin, dopamine, norepinephrine), and this exaggerates their dysphoric mood all over again.3
Other research discusses stress, family, and societal pressure's contribution to AN in people with existing obsessive or anxious personalities. These pressures can change the serotonin (5-HT) dysregulation in the brain, which will entice patients to decrease their caloric/dietary intake in attempt to change how they feel due to the serotonin changes. This decrease in food intake will inadvertently decrease the body's overall tryptophan availability (essential amino acid that is only available through the diet and is the precursor to 5-HT), which is a biological approach to regulating the 5-HT functional activity (serotonin) and thus stabilizing anxious moods. In summary, decreasing the essential amino acid tryptophan will ultimately alter the brain function through the down-regulation of 5-HT transporters and change the postsynaptic receptors in the brain neurons, which can reduce anxiety and dysphoric moods.3 To make these biological theories of AN short and sweet: Eating less may make the patient feel better temporarily to compensate for the changes in serotonin. This can be compared to a person drinking too much alcohol, which provides a temporary good feeling, followed by a horrible hangover!
Functional magnetic resonance imaging (fMRI) studies have shown that when emaciated and malnourished AN individuals are shown pictures of food, they display abnormal activity in the brain and often have an increase in anxiety.5 These results are consistent with the theory that anxiety provocation and the emotional value of an experience are stored in the brain stem. If all these theories prove to be true, one day researchers will prove that AN is caused by more than just environmental/societal influences.
Genetics and oral manifestations
Studies show AN has cross-transmission in families. The diagnosis of anorexia nervosa has been in existence for centuries, and there is substantial credibility to the hereditary nature of AN.3 Researchers believe AN to have as high a hereditary link as bipolar disorder and schizophrenia.3 Twin studies suggest AN to have a 50% to 80% hereditary link vs. environmental/societal alone. Certain DNA variations have been linked to the risk of developing AN.3 Twin studies have also found essentially no genetic influence on overall levels of AN symptoms in 11-year-old twins, but significant genetic effects (>50%) in 17-year-old twins, suggesting puberty may play a pivotal role in the expression of anorexia nervosa.4
People with AN will have severe deficiencies to their nutrient, essential amino acid, mineral, and/or vitamin intake; any deficiency or change can have multiple oral side effects. An imbalance of one or more nutrients can be a factor in the disruption of tissue integrity and immune response.9 Immune response and repair require sufficient vitamins A, C, and D, protein, carbohydrates, calcium, iron, zinc, and folic acid.9 Vitamin A is needed for salivary gland and epithelial health. Vitamin B is required for connective and epithelial tissue integrity. Vitamin C is required for collagen and connective tissue health. Vitamins A, C, and D, fluoride, and protein are needed for proper enamel and dentin formation. The calcification of alveolar bone and cementum requires certain amino acids, calcium, and phosphorus. As you can see, any fluctuation in these needed daily requirements can lead to oral damage and changes.
The dental professional's responsibility
It is hard to give advice on what a dental professional should do if he or she suspects a patient is suffering from AN. Since most people with AN deny they have an issue, even if they are extremely medically compromised, it is difficult to reach out to them. If the patient is a minor, you could have a heart-to-heart with their parents. However, I would caution you on this as well. Remember the personality characteristics of people with AN. They are overachievers and tend to be the "good" or "golden" child in a family unit. Hearing any insinuation from you that their child could have an issue such as AN may anger or insult a parent.
Anytime you speak with a patient or family member about a suspected eating disorder, it would be best to initiate the conversation with the dental problem you found. You could then list a couple of causative agents for the dental problem. For example, I had a patient a couple of years ago who was a 15-year-old white male in high school. I had seen him three or four times over the past two years and noticed at each visit that he was losing more and more weight. The last time I saw him, he was so thin, I felt I had to talk to his mom in private. I initiated the conversation like this: "Mrs. Jones, I wanted to tell you some things the doctor and I saw dentally on Josh today. He has five new cavities and his gums are unusually pale. These issues could be caused by so many things such as a change in his home oral care, diet, or any new medical issues. Would any of that apply to Josh?" I'll never forget his mom's response to my question: she started to cry. She told me she and her husband were going through a nasty divorce and that her husband was a very abusive man. He was especially cruel to Josh, and she was concerned about Josh's weight loss and change in behavior. She was thinking of taking him to a counselor but wasn't sure if she should or not. I hugged her and told her I, too, was concerned with Josh's weight changes. I recommended a couple of resources for her. I saw her again six months later at her next recare appointment, but Josh wasn't with her. I asked how he was doing and she simply said, "He's now getting the help he needs." She told me after our last conversation that she did call a therapist and now Josh was in a treatment facility for eating disorders. He had been diagnosed with anorexia nervosa -- purging type. I'll never forget that experience. If I played even a small role in Josh getting the help he needed, then that uncomfortable conversation with his mom was well worth it!
My last pearl from personal experience is this: I would never recommend asking a patient point-blank if he or she has an eating disorder or specifying anorexia nervosa. First off, you could be wrong. Secondly, if the patient does have AN, they will probably act insulted or defensive because you obviously don't think they are perfect and you are trying to "out" them on something they have worked very hard to hide from the world. I would be willing to bet the patient will never return to your office again. I would recommend a more gentle and tactful approach such as asking leading questions. These questions may make the patient a little nervous, maybe even allude to the fact you are "on to them," but it will help prevent him or her from shutting you out. Patients with AN usually will not admit to anything up front, but maybe once the person sees you a couple of times and that trust relationship begins to grow, he or she may begin to open up to you. For example:
1. "Your gums look a little pale today. Are you sure you are getting the proper amount of nutrients and vitamins daily?"
2. "You have a couple cavities today; tell me about your brushing, flossing, and diet habits."
3. "Did you know that cavities can be caused by issues in someone's diet -- not just their oral hygiene habits? You are obviously an excellent brusher and flosser, top 10% of all my patients. So, that's not the issue. Let's talk about your diet; tell me what you eat and drink on a daily basis."
Make the direction of the conversation seem dentally centered and not diet centered. This may catch someone with AN off guard and encourage them to be honest instead of thinking of ways to cover up their secret.
Regardless of what causes AN -- whether it be environment, genetics, biological, or societal pressures -- it's a tough disorder to treat and for people to fully recover from. It's a simple fact that without treatment, patients will die from AN. Unfortunately, the lives of so many young, beautiful, intelligent, and talented girls and boys are cut short because of the "reality" they have forced themselves to live in. Then, it's the family and friends who are left to mourn that loss. AN affects more than just the patient. It affects everyone around them. I encourage each one of you to take an interest in your patients' lives outside their oral cavities and you will be amazed at the changes you can produce. Five minutes of my day six years ago when I spoke with Josh's mother made a big difference in the direction and altered the course of Josh's life. What an honor it was for me to play a small role in someone else's future. RDHAccording to the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders), the criteria for AN diagnosis involves the following characteristics:
1. BMI under 17.55%
2. Fear of gaining weight or becoming fat
3. Body image disturbance by feeling they look extremely fat when at a low body weight
4. Amenorrhea due to low BMI and overall weight
According to the ADA, the below list of oral signs may be seen in someone with an eating disorder.
1. Salivary gland enlargement (due to xerostomia)
2. Dry, red, or cracked lips
3. Lesions on soft tissues that may bleed easily
4. Color change (translucency) of teeth
5. Change in the shape or length of teeth
6. Restorations may be appear elevated with erosion (usually takes six months of constant regurgitation for this effect)
7. Teeth that are temperature sensitive (hot or cold)
Any form of malnutrition can lead to periodontal changes like gingivitis-induced malnutrition or periodontal disease involving bone and tissue destruction.9 Vitamin C deficiencies can lead to widened PDLs, tooth mobility, hemorrhagic bluish-red gingiva, or collagen destruction.9 Many individuals with AN become anemic at some point in the disorder and anemia has many clinical signs and symptoms such as:2
1. Angular cheilitis
3. Scarlet tongue
4. Fissured tongue
5. Burning tongue
6. Red, depapillated, smooth tongue
7. Destruction of papillae of the tongue
8. Difficulty swallowing (dysphagia) in long-standing iron deficiency anemia
9. Pallor of tissues
10. Painful, atrophic mucosa
LISA DOWST-MAYO, RDH, BSDH, graduated magna cum laude from the Caruth School of Dental Hygiene at Baylor College of Dentistry in 2002 with a bachelor's degree in dental hygiene. She has held numerous leadership roles in the tripartite of the American/Texas/Dallas Dental Hygiene Associations. She is an author, clinician, educator, and national speaker. Lisa is a full-time dental hygiene professor at Concorde Career College in San Antonio, Texas. She has published numerous articles on a broad range of topics for both RDH and Access Magazine and has written CE courses for PennWell, Inc. She is the cofounder of DIAMOND DENTAL EDUCATION, LLC, which offers CE courses to professionals in Texas. www.diamonddentaleducation.com. She can be contacted through her website at www.lisamayordh.com.
1. Dellava J, Thornton L, Lichtenstein P, Pedersen N, Bulik C. "Impact of Broadening Definition of Anorexia Nervosa on Sample Characteristics." J.Psychiatr Res. May 2011;45(5):691-698.
2. Ibsen O, Phelan J. "Oral Pathology for the Dental Hygienist." 6th ed. Saunders Elsevier, St. Louis. 2014.
3. Kaye W. "Neurobiology of Anorexia and Bulimia Nervosa." Physiol Behav. Apr 2008;94(1):121-135. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2601682/.
4. Klump KL, McGue M, Iacono WG. Age differences in genetic and environmental influences on eating attitudes and behaviors in preadolescent and adolescent female twins. Journal of Abnormal Psychology. 2000;109(2):239–251.
5. Naruo T, Nakabeppu Y, Sagiyama K, Munemoto T, Homan N, Deguchi D, Nakajo M, Nozoe S. Characteristic regional cerebral blood flow patterns in anorexia nervosa patients with binge/purge behavior. Am J Psychiatry. 2000;157(9):1520–2.
6. Public Health Service's Office in Women's Health, Eating Disorders Information Sheet. 2000.
7. Substance Abuse and Mental Health Services Administration (SAMHSA), The Center for Mental Health Services (CMHS), offices of the U.S. Department of Health and Human Services.
8. Sullivan P. American Journal of Psychiatry. July 1995;Vol.152(7):1073-1074.
9. Stegman C, Davis J. "The Dental Hygienist's Guide to Nutritional Care." 3rd ed. Saunders Elsevier, St. Louis. 2010.
10. National Eating Disorder Association http://www.nationaleatingdisorders.org/anorexia-nervosa
11. National Association of Anorexia Nervosa and Associated Eating Disorders (ANAD) http://www.anad.org/
12. ANRED (anorexia nervosa and related eating disorders) nonprofit organization http://www.anred.com/welcome.html
13. Help Guide (nonprofit Web resource for information) http://www.helpguide.org/mental/anorexia_signs_symptoms_causes_treatment.htm
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