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Title Enamel Erosion Occurs More Frequently in Bulimic Patients Than in Anorectic Patients
Clinical Question In a patient with an eating disorder, will there be more erosion of the enamel in a bulimic versus an anorectic patient?
Clinical Bottom Line Eating disorders are associated with a wide variety of oral manifestations, but erosion of enamel, particularly the palatal and lingual surfaces, is generally seen more in the bulimic patient than in the anorectic patient.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 18826377Lo Russo/2008Subjects diagnosed with eating disorders receiving dental care. Critical review
Key resultsAs stated in the study, oral manifestations of eating disorders are often caused by nutritional deficiencies, but can also be related to poor oral hygiene, psychological problems, and modified nutritional habits. No definitive statement is made about which disease leads to more erosion, but it is suggested that different oral manifestations can be associated with anorexia and bulimia. Palatal erythema and dental erosion is more suggestive of vomiting induction whereas oral problems associated with nutritional deficiencies are more suggestive of anorexia. The authors repeatedly mention erosion in relation to the purging type, but only cite two studies about patients that use vinegar and lemon juice to diminish hunger (Jarvinen, et. al., 192; Del Signore et. al., 1998). A table is presented in the review indicates that vomiting is the main cause of dental erosions in the purging type, whereas carbonated drinks are the main cause of dental erosions in the restricting type, which would further suggest that dental erosion is more pronounced in the purging type. In addition, erosion caries are cited as the main cause for dysgeusia in the purging type patient, but is negative for the restriction type patient.
#2) 22288922Johansson/2012ED patients in outpatient therapy.Case-Controlled study
Key resultsThe patients with vomiting/binge eating behaviors reported worse perceived oral health and had more dental erosion than those without. In ED patients with a longer history of the disease, dental erosion was more common. Johansson et al reports a significantly higher odds ratio for ED patients to present dental problems (OR=4.1), burning tongue (OR=14.2), dry cracked lips (OR=9.6), dental erosion and less gingival bleeding (OR=1.1) when compared with healthy controls. Sensitivity and specificity for the correct classification of ED patients and controls using the five variables was 83% and 79%, respectively. The study also strengthens the suggestion that ED patients with vomiting/binge eating behaviors reported worse perceived oral health (OR=6.0) and had more dental erosion (OR=5.5) than those without such behavior.
Evidence Search Oral manifestations of Eating Disorders (Pubmed)
Comments on
The Evidence
The first study was a critical review that reviewed mucosal, dental, and salivary abnormalities with ED. The authors presented a review that gives a good background about how eating disorders can affect oral health, but only addresses erosion as one of the many problems that can manifest. The authors suggest that purging type behavior leads to more dental erosion, but also mentions how it manifests in restricting type behavior, so it is not the best evidence with regard to the PICO question. The study by Lo Russo et. al., is effective at educating the dentist in terms of the basic oral manifestations of eating disorders, but more information would be needed to establish a firm opinion about the disorders. The second study is a matched case-control study that reported on 54 individuals participating in a 12 month outpatient program. While it gives some valuable information regarding the oral manifestations of eating disorders, the small sample size is not enough evidence to firmly establish that bulimia causes more erosion than anorexia. In addition, these patients were in out patient treatment for their disease, so it is possible that the patients are now coming to terms with their problem and recognizing the detrimental effects EDs can have on oral health.
Applicability The results of both studies do not directly answer the above PICO question, but provide some evidence that may suggest that dental erosion is worse in bulimics than in anorexics. The two diseases are intimately linked, but it is evident in both articles that purging behavior (bulimia) leads to more erosion of enamel than restrictive behavior (anorexia), if only based upon the fact that the enamel is under constant assault by the gastric acids in the bulimic patient. The differences in which surfaces of teeth are affected is critical in determining what type of restorations should be used and the likelihood of achieving appropriate occlusal function as well as the esthetics desired by the patient. As the dentist, it is important to broach this topic sensitively and suggest possible treatment options, dental and medical, for the patient to consider if interested. It is also necessary to have an open conversation with the patient about the treatment needed and discussing how these behaviors can affect the success rate of restorations. The articles are both useful in educating the dentist but do not specifically discuss how the treatment plan would change in a patient with ED. It can be surmised that in the purging type behavior, the lingual and palatal surfaces of teeth may need closer inspection and more restorations than the facial or occlusal.
Specialty/Discipline (General Dentistry) (Restorative Dentistry) (Dental Hygiene)
Keywords Anorexia, Bulimia, Oral Manifestations, Eating disorders, Erosion
ID# 2476
Date of submission: 04/18/2013spacer
E-mail candace1633@gmail.com
Author Candace DeFratus
Co-author(s) e-mail
Faculty mentor/Co-author Georgiana S. Gross, MPH
Faculty mentor/Co-author e-mail grossg@uthscsa.edu
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