Have you found yourself treating a patient whom you suspect might have an eating disorder (ED), only to find that you stumble on your words when approaching the subject? You're not alone. Communicating with patients, in general, can be daunting at times, but broaching a delicate topic such as EDs can create barriers in communication and affect how you educate your patient.
More than 28 million Americans live with EDs,1 which means most dental practices will treat these patients—some who are open about their treatment and recovery, and others who hide it. While bulimia nervosa and anorexia nervosa are the foremost ED types, binge eating, laxative use, orthorexia, pica, compulsive exercising, and rumination disorders are other classified conditions that can occur as well.2,3
Dental professionals have many tools that can help them assess patients, and it is quite likely that they could be the first health-care personnel to recognize the clues that uncover a patient’s ED. Consequently, dental professionals must approach patients with EDs with a caring, understanding technique because these patients tend to struggle with trust. By making the wrong comment or asking questions without thinking them through, it is very likely the patient will feel ostracized. Offering a comfortable environment is crucial for patients with EDs.
Oral manifestations of EDs
Within higher educational platforms that dentists, hygienists, and assistants attend, baseline information is presented to assist in identifying EDs. The more frequently specified oral manifestations include enamel erosion, ditched fillings, sensitivity, irregular incisal edges, petechiae of the soft palate and throat, demineralization, caries, and xerostomia.2 One oral manifestation that can be overlooked is the Russell’s sign, which is a calloused area noted on the knuckles and fingers, which are used during purging.2 Dental professionals have a tendency to become so focused on the oral cavity itself that they may forget to seek clues elsewhere.
Once any oral manifestations present themselves, it will become the role of the dental professional to begin the investigative process of the patient assessment. While one may believe a patient could have an ED, composing questions in an inviting manner will be crucial in gaining the patient’s trust. Simply asking patients if they have an ED can come off as accusatory rather than investigative. Try opening the conversation with identification of the oral manifestation and use a cluster of conditions that could encompass it. For example: “Ms. Smith, I have noticed that your enamel on the back of the upper front teeth has some erosion, and the back of your throat is quite red with some broken capillary vessels. Do you have a history of any of these conditions or habits: acid reflux, sucking on lemons, bulimia, frequent coughing, or a highly acidic diet?”
By laying a foundation of various conditions, dental professionals are normalizing that enamel erosion and redness with petechiae can occur from more than one condition. Furthermore, the “taboo” topic has been inserted among other conditions, which eliminates the elephant in the room if the patient is indeed suffering from an ED.
Approaches for educating patients
Once a patient has entrusted the dental team with their ED history, it is vital to appropriately educate that patient. Dental professionals should recognize the distinct honor it can be to walk alongside a patient in the recovery process; however, the dental team must remember not to overwhelm these patients. It is highly likely that a patient with an ED history has sought treatment from an organization, which has or currently is directing the patient with their nutritive habits, mental health,2 and daily lifestyle. Inundating the patient with too much dental information, in addition to their ED treatment and recovery, could be overwhelming and counterintuitive given the circumstances of the disorder and its ramifications for the oral cavity and body from a systemic perspective.
The first step in offering oral hygiene instructions should be to ask the patient if it is OK to offer suggestions for their dental health. If permission is given, focus on one or two primary issues to implement during the appointment and have the patient work on those between their hygiene recare appointments.4 If the patient indicates they do not wish to participate in oral hygiene instructions, ask them if there is anything you might be able to assist them with, which may open a small window of opportunity to educate. Otherwise, plan to follow up at subsequent appointments to determine if the timing is more suitable. Patients with EDs tend to have moments of victory accompanied by setbacks; the next visit could be different.
In the case of patients with EDs, the recare frequency should be considered. Suggest a three-month interval to manage any disease processes that have culminated from the specific eating disorder. Patients with bulimia nervosa may need to be encouraged to rinse with water or sodium bicarbonate rinses after purging episodes to buffer the saliva.2 Those with anorexia nervosa may need encouragement in following their nutritionist’s or dietician’s plan for caloric intake to maintain energy, which can assist them in the participation of daily oral care. A patient who is diagnosed with a binge-eating disorder might need to be counseled on how to keep teeth strengthened to avoid caries if they tend to choose highly cariogenic food for their binging episodes.
Regardless, the dental team must understand that they are an extension to the patient’s treatment team within the treatment and recovery process of any ED. Furthermore, the dental team should not cross any boundaries in making specific nutritive recommendations that could inhibit a patient’s success in recovery. It is the responsibility of the nutritionist or dietician to direct patients according to their recovery treatment plan. The dental team could suggest to the patient or parent/guardian that an interdisciplinary consult among all providers in the treatment and recovery process might be prudent to encourage a multifaceted approach.
Eating disorders are mental health disorders
EDs have been indicated as mental health disorders by the National Institute of Mental Health.2 Therefore, when reviewing a medical history, it should be noted that patients with EDs may be using antidepressant or antianxiety medications, which can cause xerostomia. When a patient divulges these types of medications, one of the first questions that should follow is to determine if the patient is experiencing any “dry mouth” conditions. Be sure to expand on your questioning because it’s not enough to ask about dry mouth; you must suggest separate ways patients may notice this condition. Here are some questions to consider:
- Compared to before you were taking this/these medications, have you noticed less moisture in your mouth?
- Do you wake in the morning with a pasty, dry feeling in your mouth, especially the palate, since starting this/these medications?
- Are you finding that you are extremely thirsty throughout the day?
- Have you resorted to chewing gum or sucking on candy to maintain more moisture in your mouth? (Do not be surprised when a patient with an ED informs you that they may not be allowed to chew gum as part of their treatment process due to the artificial sweeteners in many types of gum.)5
Another significant concern is that mental health disorders can be taxing on the body. Patients may experience fatigue, which can, in turn, affect oral hygiene care. The use of antidepressant and antianxiety medications can also exacerbate fatigue. Facilitating a home-care plan that will meet the needs of each patient is wise, and reviewing/updating the plan at each recare appointment is necessary as the patient moves through the various stages of recovery.
Oral hygiene instructions
Each ED may offer distinct oral manifestations to consider when prescribing oral hygiene instructions for patients; nonetheless, use of fluoride should be at the forefront for any individuals at risk for caries. The American Dental Association recommends 2.26% fluoride varnish or 1.23% fluoride (acidulated phosphate fluoride) gel, or a prescription-strength, home-use 0.5% fluoride gel or paste or 0.09% fluoride mouthrinse for patients aged 6 or older.6 Practitioners should be vigilant with these recommendations. Suggesting electronic toothbrushes and oral irrigation devices can help alleviate potential struggles associated with fatigue. In addition, these devices are more suitable because they do the work for the patient with minimal effort required.
Interproximal care, while oftentimes forgotten or ignored by patients, is critical for all types of patients with EDs. Binge eating, for example, could include a very high consumption of cariogenic foods, which places the patient at a higher risk for caries. If interproximal care is not included in the oral hygiene regimen, there is a much greater chance of caries occurring. The role of the dental professional becomes one of suggesting a few different types of tools/products and then allowing the patient to drive the home-care plan. While it may be ideal to use string floss, the patient may not have the dexterity or patience to complete the task, which means they will likely not follow through. Floss picks can be a great substitute for string floss so long as the patient has been properly instructed on the technique. The most important thing to remember is that these patients are dealing with a plethora of life issues, and simplicity will be key with any home-care instructions, especially interproximal care that can be frustrating.
Some patients may choose to use mouthrinses to cover up malodor following a purging episode. It is especially important to consider an alcohol-free mouth rinse due to the possibility of xerostomia from excessive vomiting or use of laxatives, as well as use of any medications that can cause xerostomia. Furthermore, a correlation has been noted between EDs and other addictions, such as alcoholism, tobacco use, and drug addiction. These addictions can also be accompanied by xerostomia.7
As trusted professionals, dental clinicians are in a unique position to identify EDs and accompany patients through the treatment and recovery journey. Developing a trusting relationship with a patient who has an ED can be challenging, yet quite fulfilling. Many times, it is difficult for patients with EDs to trust because of the many circumstances they face surrounding their recovery process. Utilizing these basic concepts with your patients will be critical in offering the exceptional care they need and deserve.
Author’s note: I have experienced walking alongside a family member’s multifaceted ED journey and have developed a continuing education presentation that further explores the treatment journey patients with EDs may experience. For more information, contact me at [email protected].
Editor's note: This article appeared in the September 2022 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.
- Our work. National Eating Disorders Association. https://www.nationaleatingdisorders.org/about-us/our-work
- Sroda R, Reinhard T. Nutrition for Dental Health. 3rd ed. Wolters Kluwer; 2018.
- What are eating disorders? National Eating Disorders Association. https://www.nationaleatingdisorders.org/what-are-eating-disorders
- Wilkins EM. Clinical Practice of the Dental Hygienist. Jones & Bartlett Learning; 2016.
- Klein DA, Boudreau GS, Devlin MJ, Walsh BT. Artificial sweetener use among individuals with eating disorders. Int J Eat Disord. 2006;39(4):341-345. doi:10.1002/eat.20260
- Professionally applied and prescription-strength, home-use topical fluoride agents for caries prevention clinical practice guideline (2013). American Dental Association. https://www.ada.org/resources/research/science-and-research-institute/evidence-based-dental-research/topical-fluoride-clinical-practice-guideline.
- Mann AP, Accurso EC, Stiles-Shields C, et al. Factors associated with substance abuse in adolescents with eating disorders. J Adolesc Health. 2014;55(2):182-187. doi:10.1016/j.jadohealth.2014.01.015