Eating Disorders and Oral Health: A Dental Professional’s Role

I am a dental student who has struggled with an eating disorder. A reason I chose to enter dentistry was because dentists can play a huge role in working with patients with eating disorders. Eating disorders are more common than we think, affecting
nine percent of the world’s population and increasing in prevalence each year. They are not just a “phase,” and in fact, they can cause irreversible and even life-threatening health problems such as heart failure, permanent bone loss, stunted growth, infertility, kidney damage and more. Eating disorders have one of the highest mortality rates of all psychiatric illnesses, second only to opioid overdoses. About 26 percent of people with eating disorders attempt suicide.

Research shows early intervention means a greater chance of recovery. As dental professionals, we often see patients every six months, and we sit in a space where conversations easily flow to topics about food, diet, nutrition and more. Furthermore, the mouth is a window to the body’s health and the first place to reflect signs of nutritional deficiencies and imbalances. It is also a place that hides signs of purging not easily visible to other medical providers—but in plain sight for dental providers.

We can serve as a point of early detection if we notice habits, mindsets or oral health manifestations that point toward eating disorders. Approximately 28 percent of patients suffering from bulimia are first diagnosed during a dental exam, according to  the National Institute of Dental and Craniofacial Research.

Being Proactive & Prepared 

Dental professionals are often the first health care providers to examine and recognize patients with eating disorders, but most dentists do not take action due to fear of losing the patient, insufficient confidence in their suspicion, failure to initiate conversation due to uncertainty how to broach the issue, and lack of office protocol and practice policy.

Familiarizing Yourself the Risk

Factors There are many biological, psychological, and social risk factors at play. Biologically, having a history of dieting or negative energy balance can predispose one to an eating disorder. People with food allergies, gastrointestinal conditions (IBS, celiac disease, etc.) or diabetes are more predisposed to eating disorders due to a required focus on food, labels, numbers (weight, blood glucose, A1c) and control. In fact, a quarter of people with diabetes develop an eating disorder.

Additionally, psychological risk factors of perfectionism, body image dissatisfaction, behavioral inflexibility and co-occurring psychological conditions like anxiety, depression, substance use, obsessive-compulsive disorder and PTSD can predispose one to an eating disorder. Two-thirds of those with anorexia showed signs of an anxiety disorder (including generalized anxiety, social phobia and obsessive-compulsive disorder) before the onset of their eating disorder. Societal expectations and popular media also contribute to development of eating disorders, leading to weight stigma, teasing or bullying, appearance ideal, internalization, limited social networks, historical trauma/intergenerational trauma and acculturation. In particular, people from racial and ethnic minority groups, especially those who are undergoing rapid Westernization, may be at increased risk for developing an eating disorder due to complex interactions between stress, acculturation and body image.

Establishing Protocol and Plan

How do we become prepared? As a dental team, we can establish in-office protocols for our dental team so we are prepared to know:

• what to look for
• what to do/say when encountering a patient with an eating disorder
• how to approach treatment planning

We can publicize familiarity with eating disorders on our website and office so patients know we can be a safe space and helpful resource to them. We also can improve early detection by adding ED screening questionnaires with medical history to offer patients more options for disclosure if they do not feel comfortable with an up-front conversation.

Knowing What To Look For 

Physical Signs

When appraising a patient, we should be observant of any recent changes in their general demeanor, gait and facial symmetry. Physically, patients with anorexia may present with fluctuations in weight, hair thinning/hair loss, lanugo (a layer of soft, downy hair over their body), edema (swelling in legs/ankles), brittle nails and nail clubbing, and jaundice (yellowish skin and eyes). Patients with bulimia may look to have a more normal weight, but they may present with acute sialadenosis (“Chipmunk cheeks,” i.e., puffy, swollen cheeks), parotid gland swelling and Russell’s sign (abrasion on knuckles from self-induced vomiting).

Conversational Signs

Some warning signs in conversation can include:

• if the patient talks about frequent dieting or engagement with fad diets (keto, no carbs, no dairy, vegetarianism/veganism)
• if they show a preoccupation with weight, dieting, food, calories
• if they mention their refusal to eat certain food categories
• if they have obsessive compulsive tendencies towards oral hygiene routine
• if they complain about being cold all the time
• if they make any mentions about loss of period (for female patients)

Oral Signs

There are many dental complications for both eating disorders, often resulting from nutritional deficiencies or acid regurgitation.
For patients with anorexia, they can develop:

• canker sores
• chronic dry mouth
• angular cheilitis
• candidiasis
• Glossitis
• enamel erosion
• dry cracked lips
• tooth decay from dry mouth and impaired saliva buffering.

For patients with bulimia, they may develop:

• parotid gland swelling
• cuts/ulcerations on the soft palate and oropharynx (from insertion of objects to induce vomiting)
• globus sensation
• dental erosion on the palatal surfaces of maxillary anterior teeth
• incisal fractures and chipping
• perimylolysis in posterior teeth
• hypersensitivity + temperature sensitivity
• loss of bone density (increasing the risk of jaw fracture during extractions).

In addition to these, patients with eating disorders may develop degenerative arthritis within the temporomandibular joint, creating pain in the joint area, chronic headaches and problems chewing and opening/closing the mouth.

Establishing A Safe, Non-Judgmental Space 

When you talk to patients, try to ask questions using general terminology.

• Instead of “do you purge” you can ask “do you ever feel guilty after you eat”
• Instead of “do you have an eating disorder” you can ask “do you struggle with issues around food, eating and exercise?”

You also can ask patients about their current challenges, either health-wise or in general, to get to the root cause of any disordered eating patterns. If you suspect your patient does have an eating disorder, don’t let your hesitation of being wrong stop you from potentially helping such a patient. Always approach the conversation in a non-threatening, non-judgmental manner:

• Use “I” statements (“I have noticed”) rather than “you statements” (“you may have XYZ”).
• Focus your language on your observations, rather than the diagnosis.
  • For instance, if there is dental erosion, we can mention some possible causes (acid reflux or frequent vomiting) and give patients an opportunity for disclosure.
• Give your patient dignity but stand firm with what you observe and what you know, such as “I could be wrong, but …”
• Reference the facts. Patients may not realize the severity of the health problems of their eating disorders (multi-organ failure).
  • As a dental provider, you are in a unique position to educate your patients about the potential dental complications of eating disorders and nutritional deficiencies (mouth sores, bad breath, cracked lips, swollen gums, receding gums) and complications of frequent vomiting/purging (erosion, brittle teeth, discoloration). Make sure your patients are informed about their oral health.
• Be prepared for resistance and denial. You should speak the truth of what you see and the facts you know. However, if your patient does not want to hear them, do not push them.

Here is a sample outline of what a conversation could look like:

I wanted to check in with you. I have noticed you’ve mentioned _____ in our conversation. My inspection of your mouth shows _____. These are all signs pointing to _____. I could be wrong, but _____. I want you to know as your dentist, I am here for you. This is a safe space. You are totally welcome to say anything or nothing, but you can trust me with this knowledge that anything said here stays here.

You do not have to navigate any of this alone. I am connected to doctors and other professionals who will be of help to you. I can give you a referral, or we can work together to look for someone who fits you.

As a health professional, I also want to make sure you’re aware of the health complications of _____ such as _____. In particular, there also are dental complications of _____ such as _____. We can develop a dental treatment plan together on how to best manage your oral health.

The most important thing to establish is you are here to help, and your dental office is a safe place to disclose ED struggles and progress towards recovery. If your patient does disclose their eating disorder, they should be referred to their physician. If they decide not to, you can still be supportive and initiate prevention based on your clinical findings.

Managing Dental Care

Patients need regular dental visits for continuing care and support, and they also should be regarded as medically compromised due to the risk of dangerous medical complications, which can include cardiac arrhythmias and cardiac arrest from electrolyte imbalances, risk for osteoporosis and jaw fracture during extractions and gastric bleeding. Blood pressure should be monitored. A comprehensive medical history should be taken and reconfirmed at every visit.

In-Office Dental Care

To remineralize enamel and reduce tooth sensitivity, you can introduce in-office fluoride varnish applications and fluoride mouthrinses.

Essential restorative work should be done to limit tooth damage and relieve pain, but more permanent dental restorations such as crowns should not be completed while a patient is purging regularly (acid erosion will shorten the life of the restorations).

Home Care and Oral Hygiene Routine

The patient should be encouraged to brush three times daily with a soft brush and fluoridated toothpaste. They should be reminded to clean interproximally daily and also clean their tongue to remove biofilm and acid residue. To remineralize enamel, patients can use self-applied neutral fluoride and calcium plus phosphate products. To relieve dry mouth, patients can take saliva substitutes during the day. Xylitol products (toothpaste, gum, candies) are beneficial for salivary flow, reducing caries and reducing acidity.

It’s important to remember patients may still be purging throughout their recovery process. The patients can wear a mouthguard to protect teeth during purging episodes. Due to the high acidic content in the stomach, the patient should not brush directly after vomiting because it can scrub acids deeper into the tooth enamel and may cause more loss in tooth structure. After purging, patients can first neutralize their oral pH by adding a spoon of baking soda in a cup of water and rinsing their mouth, or a rinsing with a product with calcium and phosphate ions. They should wait at least one hour before brushing.

Throughout this process, you should keep in close communication with other medical providers, as patients may be prescribed new medications (antidepressants) that could affect their oral health (xerostomia) and dental treatment plan. Patients may also undergo refeeding syndrome that should be monitored carefully, and they may need to see other specialists to address other health complications, especially as eating disorders often lead to multi-organ damage. Elective dental procedures should get medical clearance before you perform them.

Working with a Support Team

You can remind your patient they are not alone and there are many people who can be in their support team, including:

• Primary care physician (PCP)
• Psychiatrists for medication prescription and management
• Nutritionists/registered dieticians to provide education on nutrition and meal planning
• Psychologists/Counselors for psychological therapy
• Partner, parents, other family members, friends
• School nurse/counselor (if attending school)
• Medical and dental specialists to treat other underlying health issues
• Eating disorder support group

If patients are looking for an eating disorder support group, you can encourage them to ask their doctor or therapist for a referral, call local hospitals and universities, call local eating disorder centers and clinics or visit their school’s counseling center.

Resources you can provide to your patients in the form of QR codes:

• Screening Tool for ED nationaleatingdisorders.org/screening-tool
• National Eating Disorders Support Helpline nationaleatingdisorders.org/help-support/contact-helpline
• Free and Low Cost Support Groups nationaleatingdisorders.org/free-low-cost-support
• Busting Myths about Eating Disorders nationaleatingdisorders.org/busting-myths-about-eating-disorders

Continuous Learning

While for this article, I mostly covered symptoms of anorexia and bulimia nervosa, it is important to note there are various dimensions of eating disorders such as:

• Anorexia Nervosa (AN): Persistent caloric restriction, low weight, fear of weight gain
• Bulimia Nervosa (BN): Binge eating and purging
• Binge Eating Disorder (BED): Uncontrolled, binge eating and no purging (most common eating disorder)
• Avoidant/Restrictive Food Intake Disorder (ARFID): restrictive food intake, but lacking the psychological consequences of AN
• Pica: Ingestion of non-nutritive, non-food substances (dirt, ice, soap, etc.; often related to pregnancy, iron deficiency)
• Rumination Disorder: Regurgitation of ingested food
• Orthorexia: Cutting out food groups/concern in “purity” or “healthiness” of ingredients
• Diabulimia: Where individuals intentionally take insufficient insulin to lose weight
• Bigorexia: Muscle dysmorphia (most common in men)
• Anorexia athletica: Excessive exercising to the point where it becomes detrimental to health

Reminder: eating disorders are not mutually exclusive. They often overlap (can manifest together or switch over time within a person). Your job is not to diagnose but to help support your patient and get them the proper help for recovery. Let us work together as a profession to support our patients through this journey.

Bree Zhang is a second year dental student at Columbia University College of Dental Medicine and serves as President for the Class of 2026. Passionate about dental advocacy and public health, Bree is a National Health Service Corps Scholar, the Legislative Liaison of American Student Dental Association (ASDA) District 2, and the American Public Health Association (APHA) Oral Health Section Student Liaison. Bree graduated from Brown University with an ScB in Psychology and has given a TedXBrownU talk on tackling the interdisciplinary nature of dentistry through art, music, and psychology. She is currently exploring ways to implement music therapy into medical and dental settings to decrease patient fear and anxiety. Contact her at bree101zhang@gmail.com.

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