As dental professionals, you are placed in an awkward situation when you notice a patient with the clinical signs of an eating disorder. You may be unsure about how best to approach the issue without offending or scaring off your patient from your practice. You may also be hesitant to treat the patient until he or she has admitted to having a problem.
Regardless of how you are feeling, direct and honest communication is key. I can attest to this as someone who suffered from an undetected eating disorder for 15 years, from ages 12 to 27. As a result of my disorder, I suffered severe and irreversible damage to my teeth from purging.
Although I am not a dental professional, I believe that my experience from a patient's perspective during my 15-year struggle with an eating disorder could be helpful to dental professionals who are likely to encounter patients like me at some point in their practices. I was fortunate to find an extremely skilled and knowledgeable dental professional to help restore my smile, but it took several years, a lot of dental work, and a lot of money to get to a place where I can finally say I am free from pain and confident about my smile.
There were times throughout my eating disorder journey when I encountered dental professionals who were ill-prepared to have a patient with an eating disorder in their dental chair. I say this not to criticize these dentists, but because I believe dentistry suffers from a lack of standard and effective protocol for confronting eating disorders, which leaves clinicians unprepared and unclear about how best to help their patients. As a result, some patients have fallen through the cracks—like I did—such that their teeth are irreversibly damaged.
Most importantly, I believe it is essential that the dental professional use direct communication and clear language to confront patients in a gentle way about the unusual damage eating disorders inflict on their teeth. When talking to patients, directly mention an eating disorder as a possible cause for the damage. Avoid terms such as bulimic or anorexic, because these words may make the patient feel stigmatized or defined by his or her eating disorder. Direct communication is so important, because you may be the only medical professional who notices the symptoms that are indicative of an eating disorder.
You may be the only person who is able to identify their suffering and intervene before the situation gets worse or these patients lose their lives, so please don’t take your position lightly.
Eating disorder sufferers are incredibly stealthy at hiding their problems, and many maintain a normal weight. I hid my problem for 15 years from every single person I knew and loved, including my family, friends, and boyfriend. I avoided medical doctors so that my eating disorder would not be discovered. Patients who you see in your dental chair with severe or mildly severe dental problems caused by an eating disorder are likely chronic sufferers who have had the disorder for two or more years. You may be the only person who is able to identify their suffering and intervene before the situation gets worse or these patients lose their lives, so please don’t take your position lightly. Ultimately, it was a dental professional who prompted me to seek mental health and medical services for my eating disorder, and doing so helped end my long years of suffering.
For much of the time I struggled with the disorder, particularly during my college years, the only medical professionals I came in contact with were dentists or hygienists. Unfortunately, the dentists I saw at age 19 and again at age 21 only mentioned my severe acid erosion and asked about my consumption of acidic juices. They did not ask me directly about whether an eating disorder might be the cause of my dental problems. I did not make the connection myself either.
After my appointment at age 21, I went six more years without seeing a dental professional again, as the eating disorder took full control over my life. Because no dental professional ever discussed eating disorders with me directly, I had no information about how my continued maladaptive behaviors could possibly result in destructive effects to my teeth. I believe the damage to my teeth could have been mitigated if a dental professional had lovingly confronted me when I was younger and educated me about the harm I was doing to my teeth and overall health. Hearing this from a medical professional may have helped me to confront my situation earlier.
Out of the five dentists I saw during my struggle, only one asked whether an eating disorder was the cause of the damage to my teeth. This final dentist, who ultimately helped me with my restoration and got me into medical treatment, said: “I have noticed some damage to your teeth that is unusual for someone your age. Do you know of anything that could be causing this damage?” When I gave a negative response to his question due to shame, he persisted and said, “I sometimes see this pattern of damage in patients suffering from eating disorders. Do you now or have you ever suffered from an eating disorder?”
It was only when I was asked directly whether I was suffering from an eating disorder that I was able to admit to my problem. I believe confronting your patient in a clear and straightforward manner—one that cannot be misinterpreted—is essential to breaking through the barrier of denial that is so strong in those with eating disorders. Many eating disorder sufferers, including myself, are secretly grateful to have someone notice their daily suffering and offer hope for an alternative lifestyle. It is a very hard condition to admit, which is why you, as a dental professional, may need to help your patient take that first step. However, asking about sodas, for example, does not confront the issue head-on and could mean a very serious problem remains untreated.
Don’t be angry if your patient evades your help or continues to deny that he or she has a problem.
Further, please recognize that denial is a key part of the illness. Don’t be angry if your patient evades your help or continues to deny that he or she has a problem. I wasn’t trying to deceive the dentist when I failed to mention that I was suffering from an eating disorder on the consult forms before my appointment. I was in the middle of a mental health crisis, which is defined by symptoms of anosognosia, meaning the patient is unaware or in denial of the eating disorder. I was a young person who did not fully understand the physical and mental consequences of my illness, and I was also suffering from extreme shame, which caused me to feel as if I did not deserve help for causing the damage to myself. I felt strongly that no one would want to help me with my problems and that everyone would just label me as crazy.
Unfortunately, nonverbal communication can contribute to the kind of shame that your patient feels by leaving far too much up to interpretation. Eating disorder patients have a reported hypersensitivity to anger, as well as difficulty expressing and understanding emotions; they often misinterpret the emotions of other people. I can attest to this. I often felt that all the dentists were angry with me. Now, I believe they were only trying to help me. This gave credence to my deep shame regarding my disorder and prompted me to avoid seeing a dentist for many years.
At the same time, patience is also incredibly important for the dentist who takes on an eating disorder patient. Your patient may have been suffering for several years from eating disorder behaviors, so ending these bad habits may take some time. Don't take a lack of cooperation personally, but set clear boundaries for your office that encourages your patient to face the illness and make better choices. My dentist was incredibly supportive and encouraging of me through this process, but he also made it clear that I had to acknowledge my eating disorder to receive continued help. For the first time, I knew someone believed in me and that I could conquer my habits. It didn’t happen overnight, but he did not get annoyed with me, reject me, or give up on me. It made all of the difference.
Finally, when in doubt, refer your patient to another dentist and to a mental health professional. If you don’t want to treat the patient yourself or if your patient is not being fully honest with you and you do not believe you can be of any help, don’t just send your patient away, hoping he or she will eventually sort out his or her problems. This will not happen. Your patient is not misbehaving. Your patient is suffering from a debilitating, life-threatening illness—one that is all-consuming and that has the highest mortality rate of all mental illnesses.
Many eating disorder sufferers can die not only from the physical complications of their disease, but also from an increased risk for suicide. That is why it is essential for you to intervene if you notice signs of an eating disorder. Eating disorders rarely resolve of their own accord. The risk of suicide can be heightened from long-standing pain or medical problems, such as severe dental deterioration, so it is key that you take your patient's level of pain and suffering into account. You cannot tell a person's level of suffering by outward appearance, as many sufferers go to great lengths to hide their struggles. Please try all that you can to either help your patient alleviate some of this pain under your own care, or point your patient to a specialist who is better suited to help.
Visiting the dentist may be your patient’s first attempt at self-care, so it is important that you help make this experience a positive one. A positive experience in the dental chair may give your patient the courage to continue to seek treatment from doctors and mental health professionals, leading him or her on the path to long-lasting recovery.
Editor's note: Madeline Miles is an eating disorder survivor writing under a pseudonym.