Have you or a loved one ever had a difficult relationship with food and/or weight? And have you ever wondered how restrictive or compulsive eating patterns may affect oral health? As a registered dietitian practising in Toronto, I see patients of all ages. And I can tell you that eating disorders are no longer restricted to young females with anorexia nervosa and bulimia nervosa. I now see elderly women, male teens and kids less than 10 years of age with different types of eating disorders, which have body-wide effects, including a negative impact on gums, teeth and the mouth.
When I counselled an underweight 70-year-old female who was losing weight, it took me a few sessions to figure out that she was eating less to maintain her appearance and fight aging. She had atypical anorexia. And when a young man came to see me for weight loss, it turned out that he had a binge-eating disorder. In both cases, there was no initial suspicion of an eating disorder, even from the patients themselves. If you or someone you know restricts their daily calories, has uncontrollable binging, practises self-induced vomiting or all of the above, strongly consider the possibility of an eating disorder — and seek professional advice.
Eating disorders defined
Eating disorders are a range of psychological illnesses that involve a severely distorted relationship with food, causing disturbances in eating patterns and related thoughts and emotions.
This preoccupation with food, and often body weight, negatively affects one’s physical well-being and the ability to carry out basic life functions, such as working or socializing with friends. These conditions are associated with significant medical complications, and some have the highest mortality rates among all psychiatric illnesses. Most of the research in this field has been done on females with anorexia and bulimia. Statistics show that between 0.3 per cent and 1 per cent of women have anorexia, while .9 per cent to 3 per cent of females develop bulimia. Other eating disorders include night eating syndrome and binge-eating disorder.
Eating disorders and oral health issues
Dr. Mikhail Pliousnine, a general dentist with a practice in North York, has a particular interest in patients with eating disorders. He says that “all eating disorders will have negative effects on the body…and definitely lead to a negative impact on oral health.” Also, he notes, “the deficiency of vitamins, minerals and nutrients associated with these disorders can cause the body to shut down and fail to function properly.”
Dr. Pliousnine has seen increased cavity and decay risk, moderate to severe gum disease, tooth erosion defects and increased complications after dental surgery due to the compromised immune system in patients with eating disorders. Other common oral health issues may include dry mouth, enlarged salivary glands, altered taste, increased (temperature) sensitivity and changes in the colour, shape and length of teeth. Restricting, binging and purging are the nutrition-related behaviours central to eating disorders that affect oral health the most.
Tooth erosion
Tooth erosion is common in patients with both anorexia and bulimia because vomiting leads to a significant breakdown of tooth enamel. And all patients with eating disorders, including those who don’t vomit, have higher rates of tooth erosion than the average healthy person. Erosion may be caused by the body’s own acid from self-induced vomiting or from eating low acid foods. For example: someone with binge-eating disorder may regularly drink two litres of cola at a time, while someone restricting their food intake may be eating vast amounts of citrus fruits, but avoiding most other foods. Frequent, vigorous brushing and rinsing that often immediately follow a purge also contribute to dental erosion. Dr. Beatrice Leung, a prosthodontist in Toronto, has seen both (young) male and female patients with eating disorders in her practice. She says that tooth wear caused by erosion can lead to dental sensitivity and the loss of tooth structure, which can compromise both the look and the function of teeth in those with eating disorders.
Cavities and tooth decay
Although the incidence of cavities and tooth decay in those with eating disorders varies, they are still a significant oral health problem. The risk of cavities and tooth decay depends on the dominant behaviours of the disorder and the oral hygiene practices of the individual. The reduced flow of saliva/dry mouth also increases the risk of cavities, tooth decay and other oral infections in those with eating disorders. Additionally, certain antidepressants used to help treat some eating disorders affect the production of saliva.
Periodontal disease
Patients with eating disorders, especially those who significantly restrict their daily food intake, may have poor hygiene practices leading to increased plaque buildup and inflammation of the gums, known as gingivitis. Certain micronutrient deficiencies, such as B vitamins, calcium and vitamin C, have also been linked to gingivitis. This is another consideration, as nutrient deficiencies are a common result of eating disorders.
Treatment
Eating disorders involve a number of factors and require a team approach for proper treatment. And dentists are often the first point of contact to recognize and address an eating disorder. Dr. Leung looks for obvious signs, such as weight loss or gain, lack of personal/oral hygiene and frequently missed appointments, as red flags for an eating disorder. And she stresses that “early intervention may simplify treatment.” Regular dental appointments are crucial for people with disordered eating. Dr. Pliousnine recommends specific treatment plans and maintenance schedules for those with eating disorders, “which may include instruction in proper oral hygiene, a caries [cavities and tooth decay] prevention program, restorative dentistry, dry mouth management, teeth sensitivity reduction, nutrition guidance, frequent recalls and hygiene appointments.” And, he adds, “a referral to health-care specialists would be crucial for the treatment of a complex eating disorder.”
Addressing an eating disorder is incredibly difficult and takes a lot of courage. If you notice that your or a loved one’s relationship with food is taking over and is marked by significant caloric restriction, binging or purging, discuss it with a health-care provider. From my personal experience as a dietitian, I suggest easing into this discussion with a person you trust and feel comfortable with. Whether that person is a family doctor, dentist or counsellor, they will give you the needed support and help required to build an expert team through referrals.