Oral Manifestations of Eating Disorders
Oral Manifestations of Eating Disorders
The eating disorders that tend to present with oral manifestations are anorexia nervosa and bulimia nervosa. Literature concerning specific oral manifestations of binge eating disorder and pica has not been described. However, individuals with pica presenting with iron deficiency anemia may present with glossitis (sore, smooth, and/or redness of the tongue), xerostomia, and dysphagia.58,59
Oral health findings of anorexia and bulimia vary in severity with the length of time the individual has the disorder, the degree and frequency of pathological eating behaviors, diet, and oral hygiene habits. The most common oral manifestations of eating disorders affect the dentition, salivary glands, periodontium, and oral mucosa.
The most common effect of anorexia and bulimia is tooth enamel erosion or perimylolysis associated with the chronic regurgitation of gastric contents.60-65 Hellstrom defined this condition as “a loss of enamel and dentin on the lingual surfaces of the tooth as a result of chemical and mechanical effects caused mainly by regurgitation of gastric contents and activated by movements of the tongue.”66 The hydrochloric acid contained in vomitus breaks down the enamel and dentin of the teeth as it moves through the oral cavity. Perimylolysis is usually clinically observed after the individual has been purging for at least two years.67 Miloslevic and Slade studied the orodental health of individuals with anorexia and bulimia. Findings indicated that enamel erosion only may be evident in those individuals who demonstrate frequent regurgitation. These investigators found a relationship existed between vomiting episodes and abnormally high erosion, but only when the frequency of vomiting was greater than 1,100 episodes.68
The erosion associated with eating disorders typically has a smooth, glassy appearance particularly on the palatal surfaces of the maxillary anterior teeth (Figure 1). Severe generalized destruction may occur to the extent that the pulps of the teeth may be visible. Clients with this severity of erosion may complain of thermal sensitivity, and occlusal changes. The margins of restorations on posterior teeth may appear to be ‘floating’ or higher than adjacent tooth structures (Figure 2). Other occlusal changes include anterior open bite and loss of vertical dimension caused by loss of occlusal and incisal tooth structure.10 Bruxism and clenching and abnormal swallowing habits also may contribute to loss of tooth structure.69
Some individuals demonstrate buccal erosion of the enamel surfaces. Figure 3 demonstrates erosion of the facial surfaces of both the maxillary and mandibular anterior teeth. This finding has been attributed to excessive consumption of citrus fruit drinks as part of the diet of persons with eating disorders or as a result of medications prescribed by physicians for those with anorexia. Dextrose tablets and sucrose containing vitamin C beverages have been used in the treatment of individuals with anorexia.69
The incidence of caries among persons with eating disorders appears to be variable. Individuals with anorexia tend to ingest a lower than normal amount of food. However, the proportion of carbohydrates to protein and fats is higher than in the normal population. Persons with bulimia tend to ingest high amounts of carbohydrates during episodes of binge eating. Likewise, those with binge eating disorder consume large amounts of carbohydrates. Ahigh-carbohydrate diet can lead to an increase in acid production and an increase in the risk of dental caries.
Empirical studies examining the caries rate in individuals with anorexia and bulimia reveal conflicting results. Hellstrom reported a low caries rate in one study of anorectic subjects66 and a moderately high rate of caries in a subsequent study.68 Stege, Visco-Dangler, and Rye reported a case study that revealed a high caries rate in an individual with anorexia. They attributed this finding to bingeing on high-carbohydrate foods and citrus fruits and poor oral hygiene.70 Milosevic and Slade failed to find differences in caries rate between eating disorder subjects and control subjects when comparing bitewing radiographs, DMFT scores, and the buffering capacity of saliva.68 Liew, et al. investigated the level of bacteria implicated in caries development among anorexic females and control subjects. The results of this study indicated that the anorexic and control subjects did not differ in the level of bacteria associated with caries development, salivary flow rate, or DMFT scores.71
Enlargement of the parotid glands and occasionally the sublingual glands is a frequent oral manifestation of the binge-purge cycle of individuals with eating disorders.72 The incidence of parotid swelling has been estimated to be between 10 and 66%.73 The enlargement may be unilateral or bilateral.72 The parotid swelling is soft to palpation and painless. The duct appears to be patent with a normal salivary flow and the absence of inflammation. Tylenda, et al. found greater acinar size, increased secretory granules, fatty infiltration, and noninflammatory fibrosis associated with parotid changes in individuals with bulimia.74
The occurrence and severity of parotid swelling is related to the frequency, duration, and severity of the binge-purge cycle.75 Frequent vomiting may cause a chronic work hypertrophy or an autonomic neuropathy that leads to enlarged acinar cells.76 The onset of swelling follows a binge-purge episode by two to six days.73 Initially, the enlargement may be intermittent, but eventually, it can persist. This results in a cosmetic deformity that may compel the individual to seek treatment because it affects his/her psychological state.
Reductions in salivary flow rates and xerostomia have been found in individuals who binge eat and induce vomiting or abuse laxatives and diuretics.70,74,77 Xerostomia is also a common side effect of psychotherapy medications, particularly antidepressants, prescribed for the treatment of eating disorders.
Individuals with anorexia or bulimia tend to be relatively young; therefore, they rarely have advanced periodontal disease. However, persons with eating disorders may exhibit poor oral hygiene resulting in increased gingival inflammation and gingival erythema. 63,78 Poor oral hygiene is more common in individuals with anorexia than in those with bulimia. Generally, persons with anorexia are more prone to depression and manifest less interest in oral hygiene practices. Individuals with bulimia tend to be more concerned about their appearance and are more meticulous about their oral hygiene.10
Those who binge eat and purge may demonstrate trauma to the oral mucous membranes and the pharynx. The rapid ingestion of large amounts of food and the force of regurgitation have been implicated as the cause of trauma to these tissues.61 Objects used to induce vomiting—such as fingers, combs, and pens—can cause injury to the soft palate. Other changes in the oral tissues that may be noted include dehydration, erythema, and angular cheilitis.67,78