Dental Health Professionals and Secondary Prevention of Eating Disorders

By Rita DiGioacchino DeBate

A dentist has a female patient with a history of dental erosion, dry mouth and cracks on the sides of her mouth. Ten of the patient’s teeth have required crowns due to extensive erosion. The dentist provides competent treatment within his specialty, but neither he nor the hygienist who works with him detects the larger problem behind the patient’s oral manifestations. She suffers from bulimia nervosa. Her frequent vomiting is causing her tooth erosion.

This is a compression of several case studies I have compiled in my recent research, and the facts support these general findings: Few dentists and dental hygienists are prepared to intervene with patients to accomplish secondary prevention of eating disorders – actions taken which result in early detection and early treatment.

The oral health problems associated with eating disorders are well-documented in professional journals. Dental problems resulting from anorexia nervosa and bulimia nervosa can occur as early as six months following the onset of disordered eating behaviors, such as caloric restriction and vomiting. Given that dentists and dental hygienists may be the first health care providers to see the physical and oral effects of anorexia nervosa and bulimia nervosa, they can play a vital role in helping these patients begin the process of overcoming their eating disorders.

Individuals with eating disorders have the highest mortality rate among any groups afflicted with mental illness. Twenty percent of the people who suffer from eating disorders will die prematurely from complications related to their disorder, including suicide and heart problems. Failure by the dental care provider to identify these oral manifestations may lead to serious systemic problems and irreversible damage to the oral cavity, in addition to reducing the likelihood of early treatment and case management.

Early Diagnosis, Treatment Are Keys to Recovery
Early diagnosis, referral and treatment significantly increase the chance of recovery for people with eating disorders. In spite of this, only one in 10 receives treatment. The number of individuals who are referred to care is influenced by the secondary prevention efforts of various health practitioners who are skilled in detecting the physical and oral manifestations resulting from harmful eating behaviors. Examination of the mouth, face and general appearance of the patient by the dentist or dental hygienist is a crucial first step in the secondary prevention of eating disorders and associated systemic conditions, such as intestinal problems, swollen glands, abnormal heart function and kidney complications.

Secondary prevention consists of early identification, referral and treatment of those who exhibit signs and symptoms of eating disorders. However, identifying these disorders can be difficult. Many people frequently hide or deny their behaviors.

Supported by a research grant I received from the National Institute of Dental and Craniofacial Research, of the National Institutes of Health, I assessed the readiness and capacity among dentists and dental hygienists pertaining to secondary prevention of disordered eating. Data were collected from 207 dentists and 369 hygienists practicing in the United States.

Generally speaking, the majority of both dentists and dental hygienists were observed to be in a “low state of readiness” with regard to secondary prevention of eating disorders. Fewer than 33 percent of dentists and 43 percent of dental hygienists currently assess patients for disordered eating, and only 42 percent of dentists and 44 percent of hygienists prescribe specific home dental-care instructions. Fewer than 21 percent of dentists and 20 percent of hygienists currently arrange a more frequent recall program for patients with oral manifestations of disordered eating, while fewer than 20 percent of dentists and 17 percent of dental hygienists refer these patients for treatment. Only 13 percent of the dentists and 7.3 percent of the hygienists who were surveyed reported communicating with their patients’ primary care provider.

My findings indicate that although both dentists and dental hygienists report having observed oral manifestations of disordered eating behaviors, most of them are not referring their patients for help.

Following up on my findings, I conducted a series of focus groups with dentists and dental hygienists in order to identify the barriers to approaching patients and providing referrals. Similar responses emerged from both. The qualitative data from the focus groups indicate that both dentists and hygienists believe their primary role in oral health care is to connect oral manifestations with possible systemic health issues. The majority of dentists and hygienists do agree, however, that the identification of oral manifestations of eating disorders is important due to the severe health conditions associated with these disorders. However, when asked why they do not currently engage in patient approach and referral, they gave one or more of the following reasons: lack of knowledge regarding types of eating disorders and oral manifestations, uneasiness about approaching the patients, lack of resources for patient referral and lack of practice protocol for secondary prevention delivery.

Dentists and dental hygienists told me that it would be very helpful to have a user-friendly “tool kit” they could employ as a reference and resource guide.

Based upon these findings, I was awarded a grant from Old Dominion University’s Office of Research to develop a Web-based secondary prevention tool kit for dentists and hygienists. In collaboration with Ravi Mukkamala and Ajay Gupta from the University’s computer science department, I have devised easy-to-navigate materials to educate dentists and dental hygienists in how to approach patients suspected of having eating disorders. Included are referral resources and patient-specific dental care instructions for those who engage in disordered eating behaviors.

As this is being written, I am testing the Web-based tool kit. Once revisions are made and the final version becomes available, it is my hope that the tool kit will help dentists and dental hygienists gain the knowledge and confidence they need to play a critical role in the secondary prevention of eating disorders. My ultimate goal is to integrate oral health care with mental health services, thus getting help to a greater number of people suffering from mental disorders.

Rita DiGioacchino DeBate is an associate professor of community and environmental health.