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Running head: BINGE EATING DISORDER AND ITS EFFECTS ON THE ORAL CAVITY 1 Binge Eating Disorder and its Effects on the Oral Cavity Laci Page Missouri Southern State University BINGE EATING DISORER AND ITS EFFECTS ON THE ORAL CAVITY 2 Binge Eating Disorder and Its Effect on the Oral Cavity Eating disorders, such as Binge Eating, create damaging effects on the human body and in turn, can greatly harm the oral cavity. Eating disorders effect many people today and are typically associated with an underlying psychological disorder. In many cases a dental professional may be the first person to learn of a person’s eating disorder (DeBate, Tedesco, & Kerschbaum, 2005). This gives those professionals an opportunity to introduce some sort of health intervention, whether it be presenting the patient with resources to turn to, or simply educating the patient further on the effects of their disorder. While patient education aids in the prevention of further damage that eating disorders can have on oral tissues, education among caregivers, such as dental professionals, is essential. The further educated the caregiver, the better the signs of these eating disorders can be spotted and the patient can then be educated on the detrimental effects their conditions can have on their overall health. Eating disorders often share similarities, however each one can be characterized differently. Anorexia Nervosa includes an intense fear of gaining weight and can include either “restricting” and limiting food consumption or a “binge-purge” type of anorexia where the person will restrict food intake for a period of time and then purge or vomit after eating (Steinberg, 2012). Anorexia is also increasing regularly all over the world and, unfortunately, has the highest death rate of any psychiatric disease (Szalay, 2010). Bulimia Nervosa is often characterized by binging. It often includes a fixation with eating and then a form of compensation for overeating, either by purging or the overuse of laxatives (Frydrych, Davies, & McDermott, 2005). The repeated vomiting of bulimia exposes teeth to more stomach acid than the saliva can manage. This enables the acid to dissolve the tooth enamel which can lead to tooth decay (How eating disorders affect your oral health, 2014). This is also true for Binge Eating. BINGE EATING DISORER AND ITS EFFECTS ON THE ORAL CAVITY 3 Binge Eating Disorder, or BED, is when a person consumes a large amount of food over a short amount of time (Chambers, 2009) and can be associate with Night Eating Syndrome and elevated body mass index scores (Adrian Meule, 2014). While anorexia typically comes to mind when thinking of eating disorders, BED is the most common eating disorder in the U.S. (BingeEatingDisorderAssociation, 2014). Binge Eating Disorder can incorporate the habits of bulimia and can overall be detrimental to the human body. Along with other eating disorders, BED can have both systemic and oral effects. As a health care professional, it is important to be able to spot the signs of BED, and understand the underlying psychological reasons behind this disorder. Having a good understanding of BED can aid in patient education, so they can better understand all of the effects of their eating disorder and can ultimately lead to prevention. Binge eating disorder is the most common eating disorder and consists of episodes of uncontrollable overeating. Sufferers of this disease tend to hide their binge eating episodes from other people and feel ashamed or even depressed about their overeating episodes (Chambers, 2009). BED can have many systemic effects on the body. Many complications of BED can include, gallbladder disease, type 2 diabetes, heart disease, high blood pressure, osteoarthritis, high cholesterol and even some cancers. Other systemic complications include gastrointestinal problems, depression, anxiety, polycystic ovary syndrome, joint and muscle pain as well as sleep apnea (BingeEatingDisorderAssociation, 2014). Binge-and-purge cycles can affect the body’s entire digestive system. This can lead to electrolyte and chemical imbalances which affect the heart and other major organs. The mere appearance of one or more of these signs of malnutrition does not necessarily diagnose an eating disorder, but they can present as clues so that further BINGE EATING DISORER AND ITS EFFECTS ON THE ORAL CAVITY 4 questioning and investigating can begin along with possible referral to their general doctor (Cynthia A. Stegeman & Lynne H. Slim, 2011). Oral manifestations can also develop due to Binge Eating Disorder. “The intraoral effects of eating disorders include signs of malnutrition, dental erosion, traumatized oral mucosal membranes and pharynx, dental caries, dentinal sensitivity, enlargement of the parotid glands, gingival and periodontal diseases, and soft tissue lesions.” Xerostomia, or dry mouth, often occurs due to antidepressant or antianxiety medications often prescribed to those with eating disorders (Cynthia A. Stegeman & Lynne H. Slim, 2011). Dental erosion can occur on both the front and back sides of the teeth, also known as labial (lip side) and lingual (tongue side). The lingual side of the top front teeth (or palatal surface) will commonly be eroded with a smooth and glossy appearance to them (Cynthia A. Stegeman & Lynne H. Slim, 2011). “Once the palatal surface of anterior teeth is depleted, unsupported enamel tends to crack easily and is exacerbated if the patient has parafunctional habits. Erosion can also cause hypersensitivity to touch and cold temperatures.” Also, “once cracked teeth cause inverted smiles, individuals with eating disorders may seek dental care for aesthetic reason” (Cynthia A. Stegeman & Lynne H. Slim, 2011). It is important for a dental professional, such as a dental hygienist, to be able to spot and look for oral manifestations and other signs of eating disorders. “Enlargement of the parotid glands and occasionally of the sublingual and submandibular glands are frequent oral manifestations of the binge-purge cycle in patients with eating disorders” (Steinberg, 2012). Patients who binge and purge may have reduced salivary flow. The oral mucosa and the pharynx may also be damaged by binging and purging, due to rapid ingestion of large amounts of food and forced vomiting. The soft palate may be injured by objects used to induce vomiting. Dryness, erythema and angular cheilitis have also been documented in these cases (Steinberg, BINGE EATING DISORER AND ITS EFFECTS ON THE ORAL CAVITY 5 2012). Oral ulcerations and glossitis of the tongue can also manifest. These can be signs of vitamin deficiencies, such as iron and B12. Such deficiencies need to be recognized due to their likelihood of underlying problems (Frydrych, Davies, & McDermott, 2005). Eating disorders are often accompanied by mental disorders such as depression. In fact, eating disorders, like BED, are often times one of many different symptoms of depression. Many other psychological complications are associated with eating disorders such as anxiety, selfdoubt, mood swings, distorted body image, denial of problem and feelings of alienation among others (Cynthia A. Stegeman & Lynne H. Slim, 2011). Eating disorders can also develop due to physiological changes, shame or isolation. Studies show that individuals with eating disorders tend to have higher rates of mental disorders, other compulsions and even substance abuse. These patients also often lack motivation. (Cynthia A. Stegeman & Lynne H. Slim, 2011). Eating disorders are often observed in people obsessed with not gaining weight, this is where binge eating can differ from other eating disorders. “Binge Eating is most often thought of as a maladaptive behavior associated with bulimia nervosa. However, this behavior is also noted in patients with obesity, making it of interest to study within the context of the rapidly-spreading obesity epidemic. It has been suggested that some individuals may develop addictive-like behaviors when consuming palatable foods in a binge pattern, which can lead to overeating and subsequent weight gain” (Chambers, 2009). BED can be linked to obesity. In fact, “BED is the most common eating disorder found in obese people” (Annagur, 2015). A study published in the Bulletin of Clinical Psychopharmacology compared certain test results between 149 obese study participants and 151 non-obese healthy controls. The tests assessed included a Structured Clinical Interview (SCIDI), Eating Attitudes Test (EAT), Beck Depression Inventory (BDI), and Barratt Impulsiveness BINGE EATING DISORER AND ITS EFFECTS ON THE ORAL CAVITY 6 Scale-11 (BIS-11). The results of these studies conclude that “the prevalence of BED ranges from approximately 0.3 to 7% in community samples to between 9% and 30% in obesity clinics. Most studies have found significantly higher levels of eating related and general psychiatric symptomatology in obese patients with binge eating than those without binge eating” (Annagur, 2015). These studies have shown that there is a positive correlation between BED and depression as well as a long history of affective disorders. Conditions such as paranoid ideas, psychoticism, and obsessive-compulsive disorders appear to be strongly linked to BED. The results of these studies also show that the risk of obesity is elevated among women who have BED. Binge Eating is also more prevalent in overweight women who are pursuing treatment. (Annagur, 2015) While developing different prevention outlets, internet-based “guided self-help” programs have been explored. One approach included a 12 week program of online coaching along with the self-help book Overcoming Binge Eating in a study of patients with bulimia nervosa and binge eating disorder. These guided programs showed to be far better than symptom reduction (Bauer, 2013). It is important for dental professionals to realize that it is their job to advise prevention of further damage to the patients hard and soft tissues, even in the midst of their disorder. This is true whether or not the patient is in control of their disorder. It is also important for those dental professionals to understand that these recommendations will no delay treatment sought by the patient for their eating disorder. The dental professional should adamantly stress that damage to their teeth, or hard tissue, is permanent and that the suggestions given are only short term solutions to minimized further enamel loss. (Cynthia A. Stegeman & Lynne H. Slim, 2011) Recommendations that can be made by dental professionals may include wearing a mouth guard during purging episodes, rinse with baking soda and water right after vomiting to BINGE EATING DISORER AND ITS EFFECTS ON THE ORAL CAVITY 7 help neutralized the saliva pH, not just tap water. It can also be recommended to avoid brushing the teeth right after vomiting because it can cause further damage to the enamel. Dental hygienists should use polish with fluoride and not a coarse grit prophylaxis paste. When a dental professional suspects purging behavior in a patient, intraoral photographs, radiographs and study models will be beneficial in order to chart, or monitor progression. (Cynthia A. Stegeman & Lynne H. Slim, 2011) In terms of permanent dental care, it is urged to postpone complex restorative care until the patient is psychologically stabilized with very few exceptions. “Members of the dental team play critical roles for identifying undiagnosed eating disorders. In fact, because of the visibility of oro-facial manifestations, oral health care professionals may be the first to encounter such patients and to play the important role of making appropriate referrals for further diagnostic work-up and treatment” (Steinberg, 2012). It needs to be understood that eating disorders are “silent killers” and should not be taken lightly or overlooked. If a patient is suspected of an eating disorder, they should be gently confronted, informed of the many possible complications and manifestations of their condition, and highly encouraged to pursue professional help both medically and psychologically. In regards to eating disorders, early detection and intervention is key. (Steinberg, 2012) Addressing a patient will signs of eating disorders can be a difficult task. Studies show that while dentists do feel obligated to partake in secondary prevention in patients with eating disorders, they fear misdiagnosing or offending their patients (DeBate, Tedesco, & Kerschbaum, 2005). Studies also show that these dentists are admittedly not well education on local referrals, how to approach patients on sensitive subject matter, or the oral and physical manifestations in regards to eating disorders. (Steinberg, 2012) Studies such as these help outline the need for BINGE EATING DISORER AND ITS EFFECTS ON THE ORAL CAVITY 8 dental professionals to be well educated on eating disorders such as BED, and develop office protocols for such patients. “Approaching the topic of eating disorders with a patient is difficult and requires a non-threatening, non-judgmental, and non-clinical environment to reduce anxiety in revealing a well kept secret” (Cynthia A. Stegeman & Lynne H. Slim, 2011). Dental professionals should thoroughly document all physical findings during the oral exam. It’s important to keep in mind that not all patients may be ready to open up about their condition, but those that are ready may need support. (Cynthia A. Stegeman & Lynne H. Slim, 2011) “All dental professionals should be aware of community resources for eating disorders in their area, such as an eating disorder program and provide contact information. Providing a list of reliable Internet sources may be helpful” (Cynthia A. Stegeman & Lynne H. Slim, 2011). Binge Eating Disorder is a medical condition that can cause great harm to the body and the oral cavity such as xerostomia, enlargement of the parotid, sublingual, and submandibular glands, dental erosion, sensitivity and oral lesions. Binge eating can also cause damage to the soft palate, the oropharynx and oral mucosa. This eating disorder usually has underlying psychological origin like anxiety, depression and distorted body image that can both contribute to and trigger this condition. “The recognition of disordered eating behavior requires specific knowledge about oro-dental and physical cues of disordered eating behaviors. Increasing the number of dental and dental hygiene programs that include eating disorders in the curriculum along with allocation of didactic and clinical instruction time is greatly needed” (Cynthia A. Stegeman & Lynne H. Slim, 2011). Eating disorders are increasing in the U.S. and worldwide, predominantly among adolescent and adult women. Early detection, referral, and treatment of eating disorders are essential. It is important for dental professionals like the dental hygienist to be able to recognize, BINGE EATING DISORER AND ITS EFFECTS ON THE ORAL CAVITY 9 help stop, and prevent further damage to the oral cavity. Recognition of disordered eating behavior requires continued education of the dental and physical signs of eating disorders (Cynthia A. Stegeman & Lynne H. Slim, 2011). Eating disorders, like binge eating disorder, are serious conditions. People with such conditions need help and interventions and dental professionals such as a dental hygienist may be the first step in their aid to recovery. BINGE EATING DISORER AND ITS EFFECTS ON THE ORAL CAVITY 10 References Adrian Meule, K. C. (2014). Emotional Eating Moderates the Relationship of Night Eating with. European Eating Disorders Review. Annagur, B. B. (2015). The effects of depression and impulsivity on obesity and binge eating disorder. Klinik Psikofarmakoloji Bulteni, 162-170. Bauer, S. (2013). Harnessing the Power of Technology for the Treatment and Prevention of Eating Disorders. The International Journal of Eating Disorders, 508-515. BingeEatingDisorderAssociation. (2014). Retrieved from http://bedaonline.com/: http://bedaonline.com/understanding-binge-eating-disorder/what-is-bed/ Chambers, N. (2009). Binge Eating : Psychological Factors, Symptoms and Treatment. Cynthia A. Stegeman, R. E., & Lynne H. Slim, R. M. (2011, September 8). Recognizing and Managing Eating Disorders in Dental Patients. Retrieved from DentalCare.com: http://www.dentalcare.com/media/en-US/education/ce321/ce321.pdf DeBate, R., Tedesco, L., & Kerschbaum, W. (2005). Oral Health Providers and Secondary Prevention of Disordered Eating: An Application of the Transtheoretical Model. Journal of Dental Hygiene, 79(4), 1-9. Frydrych, A., Davies, G., & McDermott, B. (2005). Eating disorders and oral health: A review of the literature. Australian Dental Journal, 6-10. How eating disorders affect your oral health. (2014). Mississauga News. Steinberg, B. (2012). Medical and Dental Implications of Eating Disorders. Journal of Dental Hygiene, 1-4. Szalay, C. (2010). Taste reactivity deficit in anorexia nervosa. Psychiatry and Clinical Neurosciences, 403-407.