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FACT SHEET: Eating Disorders (also known as “feeding and eating disorders”; includes “anorexia nervosa” [also known as “AN” and “anorexia”], “bulimia nervosa” [also known as “BN”, “bulimia”, and “ox hunger”], “binge-eating disorder” [also known as “BED” and “compulsive overeating”, and formerly known as “food addiction”], “avoidant restrictive food intake disorder” [also known as “ARFID”, and formerly known as “selective eating disorder”], “pica”, “rumination disorder” [also known as “rumination syndrome” and “mercyism”], “other specified feeding or eating disorder” [also known as “OSFED”], and unspecified feeding or eating disorder [also known as “UFED”])

Date of Publication: August 18, 2016
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Is the initiation of non-invasive dental hygiene procedures* contra-indicated?

  • No.

Is medical consult advised?  

  • Yes, if a patient/client presents with a previously undiagnosed suspected eating disorder or suspected worsening of a known eating disorder.1 Sometimes pain and discomfort related to oral complications, or effects on dental appearance, first prompt patients/clients to consult with a health professional, such as a dental hygienist or dentist. The oral health professional should be aware of community resources for eating disorders, such as an eating disorder program, and be able to provide contact information.

Is the initiation of invasive dental hygiene procedures contra-indicated?**

  • No.

Is medical consult advised? 

  • See above.

Is medical clearance required? 

  • Not typically. However, if a potentially life-threatening medical complication of the eating disorder (such as cardiac arrhythmia, heart failure, and acute kidney failure) is suspected, then clearance should be sought. Esophageal rupture (such as may occur due to excessive strain during vomiting) constitutes a medical emergency, and 911 should be promptly called for emergency medical services (EMS) if the patient/client exhibits signs/symptoms2 in the dental office.

Is antibiotic prophylaxis required?  

  • No.

Is postponing treatment advised?

  • Not typically for dental hygiene procedures. However, ideally only essential dental restorations should be performed when the patient/client is engaged in purging by vomiting; extensive, complex restorative work should be postponed until the patient/client is in treatment for the underlying eating disorder and heading for recovery.

Oral management implications

  • The dental hygienist should be alert to the signs/symptoms of eating disorders, because early detection, medical referral for care, and timely professional intervention substantially increase the likelihood of recovery.  Thus, the oral health professional has an important role to play in the secondary prevention of eating disorders, as well as in oral specific treatment.
  • Incorporation of tooth wear indices as a component of the medical history and oral examination can help detect eating disorders.
  • Persons with previously undiagnosed eating disorders may seek dental/dental hygiene care for aesthetic reasons, including cracked teeth. About 25% of patients/clients with bulimia are first detected in the context of an oral health examination.
  • Oral health risk assessment conducted in a nonjudgmental fashion will facilitate identification of treatment needs, such as the use of home fluoride modalities. Recall frequency should be informed by the risk assessment.
  • Because purging by vomiting is often accomplished by the use of the index and middle fingers of the dominant hand, cuts and bruises, as well as callus formation over time, can occur where the teeth occlude at the knuckles. The dental hygienist can easily look at these fingers for a sign of disordered eating.
  • Where regurgitation is a concern, the dental hygienist should consider polishing the patient/client’s teeth with a fluoride-containing toothpaste rather than with an abrasive prophylaxis paste.
  • Radiographs, intraoral photographs, and/or study models are useful means to record progression of damage or monitor progress at each appointment.
  • Occlusion should be assessed in patients/clients with wear facets and/or abfraction. Nightguards and/or bite splints may be a consideration.
  • Patients/clients who self-induce vomiting should be counselled not to brush immediately after purging (and to wait at least 40 minutes). Instead, they should be advised to rinse with a baking soda solution to neutralize the effects of stomach acid. Tap water rinsing is less desirable, because it reduces the protective nature of saliva.
  • Overly frequent and vigorous toothbrushing can damage tooth structure, and this behaviour should be discouraged.
  • The dental hygienist should emphasize that purging damage to the teeth is permanent, and suggestions to reduce further damage (such as wearing a mouth guard during regurgitation) offer only interim solutions to minimize enamel loss. The definitive way to stop further damage is to cease continual regurgitation.
  • Xerostomia should be managed as required.
  • Patients/clients with some eating disorders often select carbonated drinks with artificial sweeteners to control appetite and weight, which increases risk of enamel erosion. Non-acidic beverages should generally be encouraged as a better option.
  • Treatment for oral malodour includes mechanical and chemical reduction of microorganisms, as well as chemical neutralization of volatile sulfur compounds. Tongue scraping, interdental aids, and antimicrobials (e.g., chlorhexidine, triclosan, and cetylpyridinium chloride) can reduce oral bacterial load. Mouthwashes containing chlorine dioxide or zinc can neutralize malodorous sulfur compounds.
  • Cigarettes may be used by some persons with eating disorders to suppress appetite. Smoking cessation should be encouraged.3
  • Oral health professionals should consider establishing relationships with eating disorder treatment professionals. Such professional linkages can improve patients/clients’ referral to specialty care when signs/symptoms are observed in the oral health setting, as well as potentially improve oral hygiene and clinical outcomes.

Oral manifestations

  • Nearly 50% of patients/clients with anorexia nervosa are also bulimic and may show oral signs of bulimia (i.e., binge-purge behaviour).
  • Eating disorders that involve frequent vomiting can affect oral health directly via contact with vomit and indirectly via resultant nutritional deficiencies (including calcium, iron, and B vitamins). Noninflammatory parotid gland enlargement, unilaterally or bilaterally, may occur, causing the jaw to widen and appear squarer. Protrusion of the mandibular salivary glands may also occur. Xerostomia may develop (and be compounded by the dryness side-effect of certain antidepressant and anti-anxiety medications). Lips may be red, dry, and cracked. Angular cheilitis, glossitis, mucosal ulceration, bleeding tendency of the oral soft tissues, and halitosis (bad breath) can occur. Teeth may be altered in colour (translucency)4, length, and shape, and they may develop hypersensitivity to touch and cold and hot temperatures, as well as become brittle.
  • Erosion of the lingual and/or occlusal surfaces of teeth is found in nearly 90% of bulimic patients/clients due to the acidic nature of vomit, and it can occur in as little time as 6 months. Restorations, which resist the acidic oral environment of patients/clients with eating disorders, appear elevated (“island like”) when the surrounding enamel is eroded5, although longevity is undermined by continued purging activity due to continued loss of tooth structure.
  • Traumatized oral mucosal membranes and pharynx (especially on the soft palate) result from continual self-induced vomiting, manifesting as erythema, scratches, cuts, and hematomas. Signs of trauma to the soft palate and pharynx may also be caused by foreign objects, such as a spoons or toothbrushes, used to induce vomiting. Cheek and lip bites may be present. 
  • Dental caries, gingival disease (manifesting as erythema, swelling, and/or glossy appearance of the gums), periodontal disease, dentinal sensitivity, diminished taste acuity, and salivary duct stones are other oral manifestations of eating disorders.6
  • Enamel damage, tooth fractures, and gingival abrasions can result from pica.
  • Caries, enamel erosion, halitosis, and chapped lips can result from rumination disorder.
  • The jawbone may be weakened by osteoporosis occurring in persons with anorexia nervosa. As well, degenerative arthritis with the temporomandibular joint is often associated with eating disorders, manifesting as pain in the joint area, chronic headaches, and problems chewing and opening/closing the mouth.
  • Tooth abrasions may be a sign of overly frequent and vigorous brushing behaviour.
  • Smoking-related oral lesions may be present.
  • Bruxism may result from emotional stress associated with eating disorders. Abfraction may occur.

Related signs and symptoms

  • Up to 1.7 million Canadians are estimated to be currently affected by eating disorders. While anyone can suffer from an eating disorder, the disorders are most common in teenage girls and young adult women. The male-to-female prevalence ratio for both anorexia and bulimia is between 1 to 6 and 1 to 10. The etiology of eating disorders is multi-factorial, and it is theorized that a combination of psychological and biological factors leads to self-starvation, purging, and over-eating. Low self-esteem is a common characteristic in anorexia nervosa, bulimia nervosa, and binge-eating.
  • Anorexia nervosa involves an extreme fear of weight gain or becoming “fat” even though affected persons may be markedly underweight. Among females, lifetime prevalence is 0.5% to 3.7%, and the proportion of patients/clients with this disorder who fully recover is modest. Peak incidence is 15 to 19 years of age. AN is most common in white women in higher socioeconomic groups. Individuals seek to maintain a low body weight by restricting food intake (often feeling “in control” of their eating and body weight), and they may also exercise excessively and/or binge-eat followed by purging behaviours such as self-induced vomiting or misuse of enemas, laxatives, or diuretics.7 Anorexia nervosa has the highest premature mortality rate of any psychiatric disorder, with the majority of deaths being due to physiological complications of starvation. Suicide rate is also elevated.
  • Bulimia nervosa involves discrete periods of overeating (i.e., binge-eating, often involving food with high carbohydrate and fat content) – which may occur several times per week to several times per day – followed by purging (in the most common form of bulimia) or non-purging compensation activities (such as fasting or excessive exercise). Lifetime prevalence is about 3% in females and 1% in males, with about the same rate in higher- and lower-income people. Onset tends to be later than AN, typically ranging from 10 to 29 years. During the binge, the individual often feels out of control, and feelings of panic, disgust, or guilt set in. After the binge, the affected person engages in compensatory behaviours – usually of a purging nature – such as self-induced vomiting or misuse of enemas, laxatives, or diuretics. Persons with bulimia nervosa often have normal body weight.
  • Binge-eating disorder affects nearly as many men as women, and is typically seen in middle-aged obese persons. Lifetime prevalence is about 2% for all people in Canada, with peak age of onset in late adolescence or early adulthood. The term describes individuals who binge-eat but do not routinely engage in inappropriate weight control behaviours such as fasting or purging. A sense of loss of control often accompanies the rapid consumption of large amounts of food, and feelings of guilt or shame may lead to repeated episodes of binge-eating. This condition tends not to be as disabling as anorexia or bulimia.
  • Avoidant restrictive food disorder is a condition where persons limit the amount or type of food eaten. Unlike people with anorexia nervosa, persons with ARFID do not have extreme fear of gaining weight or have a distorted body image. ARFID usually has an earlier onset than other eating disorders, and it is most common in middle childhood. A child with ARFID typically does not eat enough calories to grow and develop properly8, and an adult with ARFID typically does not eat enough calories to maintain basic body function.
  • Pica is an eating disorder that involves persistent ingestion (for at least one month) of non-nutritive, non-food substances (such as dirt, hair, pebbles, soap, chalk, and paint chips) inappropriate to the developmental level of the individual. Persons with pica are at risk of poisoning (e.g., from lead), acquisition of parasites and bacteria, and intestinal obstruction and perforation. Pica frequently occurs with other mental health disorders associated with impaired functioning (e.g., autism spectrum disorder, schizophrenia, and intellectual disability). Pica can affect children, adolescents, and adults of any gender, and the incidence is higher in developing countries, possibly related to food insecurity, iron deficiency anemia, and malnutrition. Although often thought of as a predominantly early childhood behaviour, pica was found in European studies to occur recurrently in about 1% of adults and 5% of youth aged 7 to 14 years. Worldwide, about a quarter of pregnant women exhibit pica behaviours.
  • Rumination disorder is characterized by unforced, repetitive regurgitation of newly ingested food from the stomach into the oral cavity for a period of at least one month (and which is not due to another medical condition). The regurgitated food may be spit out, re-chewed, or re-swallowed.
  • Patients/clients with eating disorders can exhibit numerous signs and symptoms, such as: secretive eating patterns; lack of appetite or interest in food (in ARFID); defecation difficulties (including chronic constipation that results from lethargic colon secondary to laxative abuse); abdominal pain, upset stomach, or other gastrointestinal issues with no known other cause (in ARFID); dramatic loss of weight (in anorexia and ARFID) or fluctuations in weight (in bulimia); hair loss, cold intolerance, dry skin, bradycardia (slow heart rate), disruption of menstrual cycle, and infertility (in anorexia); and chronic sore throat, electrolyte imbalance9, dehydration, and irregular heart rhythms (in bulimic behaviour). Manifestations particularly associated with anorexia nervosa include: fatigue, lethargy, fainting, mental fuzziness, hypoglycemia, anemia, osteopenia, osteoporosis, delayed and permanently stunted growth, anal and bladder incontinence (associated with weak and damaged pelvic floor muscles), drop in internal body temperature (causing a person to continually feel cold), multiorgan failure, and brain damage.
  • Eating disorders can deprive the body of nutrients needed for maintenance of good health. Signs of malnutrition (particularly in persons with anorexia) include emaciated appearance (such as broomstick-like arms and legs); thin, dry, brittle, and reduced scalp hair; dry and brittle nails; cold sensitivity; and development of lanugo hair10. Heart rate slows, and blood pressure drops.
  • Heart arrhythmias, heart failure, kidney failure and associated electrolyte imbalance (particularly hypokalemia and related metabolic alkalosis), liver damage, and aspiration or rupture of the esophagus or stomach (from continual vomiting) can lead to death.
  • Chronic ipecac syrup ingestion to induce vomiting can lead to fatal myocardial infarction. 
  • Compulsive overeating can cause obesity, predisposing the patient/client to diabetes mellitus.
  • Quality of life is negatively impacted by eating disorders. This includes damage to self-image and relationships with families and friends, as well as impaired school or work performance.
  • Depression, anxiety, obsessive-compulsive behaviour, and substance misuse occur at elevated rates in patients/clients with eating disorders.
  • Stigmatization of eating disorders means that many affected persons suffer in silence.

References and sources of more detailed information


Date: July 20, 2016
Revised: September 16, 2019; June 23, 2024


FOOTNOTES

1 While a hitherto undiagnosed patient/client with an eating disorder will likely be first referred to a primary care provider (e.g., family physician) by a dental hygienist practising in Ontario, the patient/client may go on to receive specialized psychiatric and medical care for these primarily psychosomatic, mental health disorders. Dietician engagement for nutritional counselling is also often important. With regard to rumination disorder, the main treatment is behavioural therapy (e.g., diaphragmatic breathing) to stop regurgitation.
2 Signs/symptoms of esophageal rupture include: chest pain, shortness of breath, difficulty swallowing, elevated heart rate, nausea, vomiting of blood, low blood pressure, and fever.
3 The Canadian Cancer Society, facilitated by Government of Ontario funding, offers a free, confidential Smokers’ Helpline for smokers (and vapers) in Ontario via TeleHealth Ontario at 1-866-797-0000 or 1-877-513-5333. Smokers’ Helpline Online is available at www.smokershelpline.ca.
4 In particular, the palatal surfaces of the maxillary anterior teeth are sometimes eroded with a glossy, smooth appearance.
5 Perimylolysis is the term applied to the wearing down of tooth enamel by mechanical or chemical means, the latter including repeated vomiting. It is sometimes characterized by loss of enamel with rounded margins, a notched appearance of the incisal surfaces of anterior teeth, and reduced contours on unrestored teeth.
6 Binge-eating disorder can lead to obesity, which in turn can lead to diabetes with associated gum disease. Tooth decay due to repeated snacking may also be a problem.
7 Anorexia nervosa is categorized into two major types: restricting, in which dietary limitation is the dominant feature, and binge-eating/purging, which resembles bulimia.
8 While many children go through phases of picky eating, children with ARFID experience adverse growth and development consequences.
9 Electrolyte disturbances also occur in rumination disorder.
10 Lanugo hair is soft, downy, unpigmented body hair, which is usually found on fetuses or newborn babies. When found in adults, it is almost exclusively related to anorexia nervosa.


* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.