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Essay: Dental implications of eating disorders

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Eating disorders are a type of psychological disorder characterised by abnormal or unhealthy eating habits, usually linked with restrictive food intake . The cause of onset cannot be linked to one reason alone as it is believed that there are multiple contributing factors, including biological, sociocultural and psychological influences. The sociocultural influences are linked with western beauty ideals that have recently been engraved into modern society, due to the increasing importance of social media and its dictation of the ideal body type. Studies show that eating disorders are significantly less common within cultures that have yet to be exposed to these ideals . The most commonly diagnosed disorders include anorexia nervosa (AN) and bulimia nervosa (BN), affecting more women than men (both AN and BM occur in ratios of 3:1, females to males) . Anorexia is a persistent restriction of energy intake and can be linked with obsessive behaviours that stem from severe body dysmorphia and fear of gaining weight. Bulimia is defined by repeated episodes of binge eating followed by measures to prevent weight gain such as forced regurgitation of stomach contents. The effects on an individual’s mental and physical health are commonly recognised, however dental implications may often be overlooked. The unknown cause of eating disorders increases the extent of their significance on dental health because without a definite root cause, it is difficult and sometimes even impossible to ‘cure’ an eating disorder ,thus, preventing the dental implications is more difficult. Association between eating disorders and oral health problems was initially reported in the late 1970’s therefore the established link is relatively recent . Oral complications may be the first and sometimes only clue to an underlying eating disorder. In the US, 28% of all bulimic patients were first diagnosed with bulimia during a dental appointment and this highlights the visibly clear and distinct impact that eating disorders can have on teeth . This report will investigate the main dental implications that may be caused by eating disorders. The significance will be analysed by looking at what causes the dental problems and how greatly these can be linked directly to eating disorders. The extent of significance will be analysed through looking at the extent of impact and whether these impacts are permanent or reversible.

Oral manifestations of nutritional deficiencies

Anorexia Nervosa is characterised by restriction of food intake and an extreme fear of weight gain, therefore it is common that sufferers are often malnourished and vitamin deficient. Aside from obvious health risks, these factors also lead to several oral manifestations. However, dietary patterns show great variability and will usually differ dependent on the individual. Dietary patterns include calorie restricting, eating healthily but at irregular intervals, binge eating, vomiting and fasting for prolonged periods . Therefore, there are limitations to the conclusions we can draw as to the significance of the effects on oral health, since there is an inconsistency in the contents and habits of daily food consumption. When calorie restriction is involved, as an attempt to keep major bodily functions running steadily, the body will attempt to salvage protein, vitamins and other nutrients and consequently, oral maintenance will be neglected . Studies show that patients with anorexia presented diets containing significantly lower values of all major nutrients compared with controls and specifically, intakes of vitamin A, vitamin C and calcium below RDA levels (recommended dietary values) were present in the majority of patients. However, low intakes (below RDA values) of vitamin B1, B2 and B3 were only reported in a few cases . In contrast to these findings, another source states that there is a clear reduced intake of B vitamins in anorexic and bulimic patients . A possible explanation for these results may be due to the previously discussed inconsistency in the daily intake of individuals with eating disorders but overall we can assume that nutrient deficiencies with varying severities are present in the majority of the anorexic population. The common deficiencies: vitamin D, vitamin C, vitamin B and vitamin A are associated with certain disturbances in the oral structure because they are essential for maintaining good oral health. A lack of vitamin A is related to enamel hypoplasia, which consists of horizontal or linear hypoplastic grooves in the enamel. Vitamin B deficiencies cause complications such as a painful, burning sensation of the tongue, aphthous stomatitis (benign mouth ulcers) and atrophic glossitis (smooth, glossy appearance of the tongue and is often tender). A lack of Vitamin A is responsible for infections in the oral cavity as the deficiency can lead to the loss of salivary gland function (salivary gland atrophy) which acts to reduce the defense capacity of the oral cavity, as well as inhibiting its ability to buffer the plaque acids. Inability to buffer these plaque acids could lead to an increased risk of dental caries. Additionally, vitamin B deficiencies can induce angular cheilitis; a condition that can last from days to years and is consists of inflammations focused in the corners of the mouth, causing irritated, red and itchy skin; often accompanied by a painful sensation. There is a consistency in the evaluation of calcium deficiencies among sufferers of eating disorders and this has clear significant impact on oral health. There is an established relationship between calcium intake and periodontal diseases therefore having an eating disorder increases a person’s susceptibility . The process of building density in the alveolar bone that surrounds and supports the teeth is primarily reliant on calcium. Alveolar bone cannot grow back so calcium is needed to stimulate its repair. This is important because the loss of alveolar bone can expose sensitive root surfaces of teeth, which can progress to further oral complications . If patients are not absorbing enough vitamin C, after an extended period there is a chance that they will develop osteoporosis. Although this is rare and most common amongst individuals with anorexia, it can lead to serious consequences because alongside the loss of density in the alveolar bone, it can progress to the loosening and eventually, loss of teeth: a permanent defect. With anorexic and bulimic patients, there is an increased likelihood of halitosis (bad breath) because in the absence of necessary vitamins and minerals, the body is unable to maintain the health of the oral cavity . If the vitamin C deficiency that most patients with eating disorders suffer from is prolonged and sufficiently severe, then there is a risk of scurvy development. In general, therefore, it seems that the nutritional deficiencies caused by anorexia and bulimia are significantly impacting oral health in ways ranging from unpleasant breath and physical defects to permanent loss of oral structures that need to be tackled with medical and cosmetic interventions.

Periodontal disease

As explained earlier when discussing calcium deficiency, the risk of periodontal disease may increase if an individual suffers from an eating disorder. General malnourishment is another factor that causes a quicker onset of periodontal disease, which always begins with gingivitis and only occurs in the presence of dental plaque . As discussed above, the relationship between calcium intake and periodontal disease is potentially controversial, except in rare cases of severe nutritional deficiency states. Patients dealing with extreme cases of anorexia nervosa may fall under this category. Due to the intense psychological nature of this disorder, the extremity of food restriction is likely to progress further as the need to lose weight quickly transforms into an addiction. After studying nutritionally deficient animals, the conclusions drawn suggest that nutritional factors alone are not capable of initiating periodontal diseases but are able to have an effect on their progression . This would suggest that having an eating disorder does not place an individual at greater risk of initiating periodontal diseases compared to an average person, despite their malnourished conditions. However, catalysing the progression of gingivitis into periodontal disease does suggest that having an eating disorder places patients at a significantly greater risk because their untreated gingivitis will evolve into periodontitis at a greater rate. This effect is significant because periodontitis is an irreversible condition that causes permanent damage. The evidence is limited; however, as it is based on animal research and may only accurately correspond to humans at a limited degree.

Turning now to the experimental evidence on the idea that dental plaque is an essential etiological agent in chronic periodontal diseases. It has been proven through experiments involving the isolation of human plaque and the introduction of the plaque bacteria into the mouths of gnotobiotic animals that a link exists between the bacteria in dental plaque and periodontal disease. Supporting this idea, epidemiological studies produced evidence to suggest a strong positive correlation between dental plaque and the severity of periodontal disease. Unlike some previous evidence mentioned, different clinical experiments done on both animals and humans show major findings that the accumulation of dental plaque is a result of withdrawing oral hygiene in initially healthy mouths . There is evidence to suggest that bulimics manifest a significantly higher retention of dental plaque so consequently, this disorder put patients at a greater risk of not only advancement into periodontal disease, but an increased risk of severe periodontal disease . As mentioned earlier, periodontal disease only occurs after the development of gingivitis, which consists of three stages: initial lesion, early lesion and established lesion. When an advanced lesion is present, it corresponds to chronic periodontitis: “a disease characterized by destruction of the connective tissue attachment of the root of the tooth, loss of alveolar bone, and pocket formation” . After discussing the increased likelihood of dental plaque being present in the mouths of bulimics, the strong association between dental plaque and periodontal disease can be linked directly to prove the significance of bulimia’s effects on oral health. Although the evidence is not as conclusive, anorexic patients are liable to malnourishment and since nutritional factors aid the development of gingivitis into periodontal disease, there is a significantly increased chance of anorexic patient’s oral condition transitioning from gingivitis to periodontal disease. This is extremely significant because unlike gingivitis, the oral damage of periodontal disease will be irreversible.

Eating disorders and caries

This increased likelihood of periodontal disease means that an individual is more likely to retain dental plaque, a significant factor that contributes to dental caries. Tooth decay (also known as dental caries), is defined as “the demineralisation of the inorganic part of the tooth structure with the dissolution of the organic substance”. It involves the anaerobic respiration of consumed dietary sugars where the organic acids formed in the dental plaque can demineralise the enamel and dentine . A possible contributing factor to dental caries is a common unhealthy habit adopted by people with eating disorders that involves the consumption of acidic drinks containing zero calories, an example being coke zero. According to professor colon, certain patients will drink as much as 6 litres a day in an attempt to reduce hunger and help with the process of SIV (self-induced vomiting). During episodes of “binge eating” (more common with bulimia), an individual will consume large amounts of food, usually high in sugar or fat within a short timeframe, usually with the intention of regurgitating the contents shortly afterwards. Increased amounts of sugary foods are ingested during this period, leading to an increased risk of dental caries . A study shows that prolonged periods of dietary restraint in anorexic patients did not result in changes to the bacteria associated with dental caries and consequently allows us to understand that malnourishment is not a significant factor when it comes to the risk of dental caries . Due to obsessive personality traits seen in anorexic patients, it is likely that these individuals are more fastidious in their oral hygiene, which discards dental caries as a risk compared to other complications such as dental erosion, which is to be explored later on. Although dental caries does not seem to arise as a direct issue, studies show that patients with anorexia had greater DMFS scores (decayed, missing and filled surfaces) than controls . This is likely a cause of previous factors such as the consumption of low calorie acidic drinks, not the restricted dietary intake.

Bulimia seems to place individuals at a significantly greater risk of dental caries than anorexia. A study of 33 females showed that bulimics had more intense caries when compared to healthy, age and sex matched controls . Another more recently discovered habit is CHSP (chewing and spitting) where an individual can seemingly “enjoy” the taste of certain foods by chewing the food for some time before proceeding to spit it out to avoid consuming any calories. A study shows that 34% of hospitalized eating disorder patients admitted to at least one episode of chewing and spitting in the month prior to admission . This habit can significantly increase dental problems by leading to cavities and tooth decay, presumably due to the high probability of excess residual carbohydrates. This assumption derives from the etiology of how dental caries progresses, which involves the action of acids on the enamel surface. When dietary carbohydrates react with bacteria present in the dental plaque, the acid formed initiates the process of decalcifying tooth substance and subsequently causes disintegration of the oral matrix. Abundant extracellular polysaccharides can increase the bulk of plaque inside the mouth, which interferes with the outward diffusion of acids and the inward diffusion of saliva. Since saliva has buffering properties and acts as a defence against caries by maintaining Ph, interference with the abundance of reduces defence against tooth decay. Dietary sugars diffuse rapidly through plaque and are converted to acids by the bacterial metabolism. Acid is generated within the substance of plaque to such an extent that enamel may dissolve and enamel caries leads to cavity formation. Binge eating or CHSP increases the acidity of plaque since ten minutes after ingesting sugar, the Ph of plaque may fall as much as two units. To support the scientific explanation, there is evidence supporting the association between carbohydrate intake and dental caries. For example, the decrease in prevalence of dental caries during WWII due to sucrose shortages followed by a rise in previous levels during the post-war period, following the increased availability of sucrose. Hopewood House (a childrens home) excluded sucrose and white bread from the diet: children had low caries rates which increased dramatically when they moved out. Alongside this, intrinsic factors such as tooth position, tooth morphology and enamel structure also affect the risk of caries development and this does not link directly to eating disorders because these variables differ throughout the whole population. However, an extrinsic factor that may reduce the incidence of caries is a greater proportion of fat in the diet because phosphates can reduce the cariogenic effect of sugar . Since individuals with anorexia generally avoid foods with high fat content, they are unlikely to ingest the necessary amount of phosphates to reduce their risk of caries. The evidence all relates to the significance of eating disorders (specifically bulimia) and the role they play to increase the likelihood of caries due to incidences of binge eating, CHSP, low fat intake and consumption of acidic drinks high in sugar.

Oral consequences of medication

After discussing dental caries, it is evident that saliva plays an important role in the maintenance of a healthy oral cavity. 20 women with bulimia and 20 age and gender matched controls were studied and the results showed that the unstimulated whole saliva flow rate (UWS) was reduced in the bulimic group, mainly due to medication . Although the UWS was affected, no major compositional salivary changes were found. This information is contrasted by another study that found bulimic patients did not present evidence of lower salivary flow rates but did have more acidic saliva . Another study was conclusive with the first one and found that the stimulated and resting salivary flow was poor amongst bulimic individuals compared to healthy controls. It also found that Ph levels of saliva were lower than the control group but were still within the normal range . Due to the range in findings and the limited sample size in the studies, these results are inconclusive in places and need to be interpreted with caution. However, it would make sense that habits that accompany eating disorders such as fasting or vomiting would potentially cause dehydration and result in a lower UWS.

Although we are unable to determine a strong link between eating disorders and their effect on saliva, there is conclusive evidence to support oral reactions to medication. If an eating disorder has been diagnosed, selective serotonin reuptake inhibitors such as fluoxetine (a common antidepressant), anti-psychotics and anti-cholinergic medication may be prescribed . Smith and Burtner (1994) found that 80.5% of the time, xerostomia (dry mouth) was a side effect of medications. Direct oral effects of xerostomia include diminishment or absence of saliva as well as alterations in saliva composition. These medications also have indirect effects on oral health by causing lethargy, fatigue and lack of motor control which can cause impairments in an individual’s ability to practice a good oral hygiene technique. The medications have anticolinergic of antimuscaric effects which block the actions of the parasympathetic system by inhibiting the effects of its neurotransmitter, acetylcholine on the salivary gland receptors meaning that it cannot bind to its receptors and consequently, the salivary glands cannot secrete saliva. The reason this causes such an immense impact on oral health is because of how important the functions of saliva in the mouth are. They include protection of the oral mucosa, chemical buffering (as mentioned previously when discussing dental caries), digestion, taste, antimicrobial action and maintenance of teeth integrity. Saliva contains glycoproteins that increase its viscosity and helps form a protective barrier against microbial toxins and minor trauma, protecting oral health both chemically and physically. However, a study by Nagler (2004) found that in up to one third of cases, xerostomia does not lead to a real reduction in salivary flow rate therefore this is a limitation to consider . Patients with xerostomia may experience difficulty chewing, swallowing or speaking and salivary glands may swell intermittently or chronically. Physical defects include cracked, peeling lips, a smoothed, reddened tongue and a thinner, reddened oral mucosa (the membrane lining the inside of the mouth). There are links between xerostomia and previously discussed oral complications as there was often a marked increase in caries and patients experiencing dry mouth where tooth decay could be rapid and progressive even in the presence of excellent hygiene . Overall, the extent of the impact caused by eating disorders in respect to xerostomia and a decreased salivary flow rate is fairly minimal for a few reasons. First, evidence related to salivary flow rate is inconclusive and there are several contrasting studies, therefore a confident assumption linking eating disorders to salivary flow rate cannot be made. On the other hand, there is a handful of strong evidence to suggest that xerostomia can be caused by medication which can then affect the flow of saliva, however, in terms of eating disorders, the link is weak and not exclusive. This is due to the simple fact that medication is taken by a large sum of the population for different conditions ranging from depression to heart disease. Therefore, eating disorders are not uniquely responsible for causing xerostomia. As well as this, xerostomia is a secondary effect because it is the medication that is responsible for the oral complication, not the psychological disorder. This gives reason to infer that eating disorders do not have a highly significant impact on this aspect of oral health.

Self-induced vomiting:

The most common symptom associated with bulimia is the binge-purge cycle. This involves an individual consuming large quantities of food in a short time period (binging), followed by an attempt to not gain weight by making themselves vomit or taking laxatives (purging). Linked with the previously discussed issue of xerostomia, since laxatives are medication, frequent use will significantly increase a patient’s likelihood of alterations in saliva contents and flow rate, which can lead to more significant dental issues. A case study evaluates a 25-year-old female patient who had suffered with bulimia for five years. It was found that this particular individual vomited 5-7 times per day and suffered from swelling on both sides of her face and mandible (lower jawbone). Although her symptoms were painless, on physical examination observations showed that she had bilateral enlargement of parotid glands despite a lack of tenderness in response to palpation. She had a reddened posterior pharynx and suffered enamel erosion on lingual surfaces of her maxillary teeth, likely due to the direct contact they come into with gastric acid and vomitus. After 2 weeks of no purging episodes, parotid swelling could no longer be observed, suggesting that this effect is reversible after a short period. However, after a 6-month gap, the patient returned with more severe bilateral swelling, submandibular gland enlargement and new complaints of tender, painful parotid glands. This suggests that persistent, frequent self-induced vomiting over a substantially extended duration can increase the severity of symptoms and reduces the chance of reversing these symptoms. Supporting this, when the patient was advised to use warm compresses and tart candies as forms of treatment that had previously worked, after this 6 month period there was no decrease in her gland size prior to using these treatments. This case study demonstrates the sheer significance of bulimia on dental health due to the severity of the consequences. Bulimic habits are difficult to change because even after working with a therapist, several relapses were experienced by the patient. After lack of improvements following the use of suggested treatments, the next potential option would be surgery to remove the patient’s parotid glands This would have a serious and significant impact, as there are risks of morbidity and facial scarring. As well as this, after a certain threshold, changes are irreversible and require the intervention of invasive procedures. .

The rapid ingestion of large amounts of food followed by forceful regurgitation may lead to trauma in oral mucous membranes due to insertion of fingers or foreign objects down the throat. This includes physical defects such as redness, scratches, cuts in the mouth and soft palate damage (upper surface of the mouth) as well as the previously mentioned salivary gland enlargements. These include enlargement of the parotid glands and occasionally of the sublingual and submandibular glands. Soft palate damage is often accompanied by cuts of bruises on the knuckles as a result of pressure on the skin from their teeth during an attempt to purge. However, enlargement of salivary glands will only occur if a binge-purge cycle becomes regular and frequent. Bulimic episodes and certain types of food can increase exposure to gastroesophageal reflux which often takes place during the night, meaning the patient is unaware, thus increasing the damaged caused because no measures are taken to prevent repercussions .

As mentioned earlier in the case study, a common and significant effect of self-induced vomiting is the onset of dental erosion due to acidic contents coming into repeated contact with tooth surfaces. After a while, these chemical alterations can become permanent and have exponentially negative effects.

DENTAL EROSION

Dental erosion is arguably the most commonly experienced complication amongst individuals with eating disorders, especially bulimia. It can be defined as the “irreversible process of demineralization of the external layers of tissues of the tooth” .The effects of gastric acid cause repeated purging to wear away at tooth enamel until it almost disappears and exposes sensitive dentine, the layer beneath the enamel. Dietary erosion is also a significant factor and happens mainly due to excessive intake of acidic beverages, which is a clear issue as discussed earlier when exploring dietary habits involved with anorexia. Microradiography has shown a gradual demineralisation of the surface enamel to a depth of about 100 micrometers . In a study comparing bulimics to healthy controls, results showed that the bulimia group experienced more dental erosion. There was a direct correlation between erosion and the duration of their disorder meaning that longer durations of the disorder can lead to a greater frequency and severity of dental erosion . Another study that supports these findings shows that patients with eating disorders had 5 times the odds of dental erosion compared with controls. For patients with self-induced vomiting, the erosion rate was 7 times higher. Overall, between 35% and 38% of patients with an eating disorder suffer from tooth erosion but again, patients with self-induced vomiting are at greater risk .

Linking back to the association between the duration of the disorder and its severity, erosive effects of regular vomiting are observable within the first 6 months. The effects initially observed on palatal surfaces of the maxillary anterior teeth because this is where the acid comes into contact. According to a different source, 86% of bulimic patients in a study had tooth erosion, compared to 0% of the non-vomiting group. Similar studies compared the severity of erosion linked with behavior following a “purge” which included rinsing with water, teeth brushing and no action. The results showed a statistically significant difference between dental erosion severity and found that patients who brushed their teeth straight afterwards experienced a greater level of erosion . This is most likely in an attempt to remove the unpleasant aftertaste or perhaps even a belief that brushing will reduce the damage done despite this having quite the opposite effect. A regular binge-purge cycle causes perimylolysis: the decalcification of the teeth from exposure to gastric acid. This begins with smooth erosion of the tooth enamel followed by the loss of enamel and eventually dentin on lingual surfaces of teeth. Both the chemical and mechanical effects of regurgitation cause this. After a duration of 2 years, the posterior teeth are affected and this leads to the loss of occlusal anatomy due to eroded surfaces. Teeth shape are affected and an individual may suffer from an anterior open bite and loss of vertical dimension of occlusion .

Dental erosion wears away the natural protective barrier of teeth, leaving the dentin exposed. This can cause complications such as hypersensitivity to cold, hot and sweet food or drink. The occlusal changes can lead to pain resulting from jaw movements and potentially even trigeminal neuralgia (a chronic pain condition that effects the trigeminal nerve) which causes extreme amounts of pain from simple movements such as teeth brushing which would further deteriorate an individual’s dental health. However, there are findings that do not support the previous evidence. Teeth were taken from a deceased patient and even after 4 years of daily regurgitation, almost a normal thickness of at-risk enamel surfaces were observed. Calcium, phosphate and fluoride-rich crystalline deposits were found and this shows that if oral hygiene measures are frequent and correct, this can substantially minimise the erosion of enamel . This evidence is a potential limitation because the results are specific to one case. However, we can conclude that there is evidence supporting the possibility of preventing dental erosion, even when an individual’s behavior includes daily self-induced vomiting. This means that the effect of bulimia on oral health can be slightly less significant because harmful effects in regards to erosion are avoidable. On the contrary, once erosion has developed, it is a permanent oral defect.

ATTRITION AND ABRASION

Acid eroded enamel is more susceptible to physical tooth wear than unharmed enamel which consequently places anorexic and bulimic patients at a greater risk. There are two types of physical tooth wear: attrition and abrasion.

Attrition is the loss of tooth surface due to tooth-to-tooth contact. Pathological attrition can result from bruxism, both of which can be attributed to eating disorders. Stress can be another influential factor that increases likelihood of bruxism. Bruxism is the action of excessive tooth grinding or jaw clenching and can be attributed to eating disorders and stress which is also highly prevalent in eating disorder patients. Attrition can lead to exposure of the dentine which can cause hypersensitivity.

Abrasion is defined as the “pathological wearing away of tooth substance by the friction of a foreign body independent of occlusion”. Due to excessive brushing habits previously mentioned, abrasion can be an issue for patients with eating disorders, particularly those who partake in SIV. This is due to the increased susceptibility to abrasion when patients brush teeth with soft, demineralised surfaces. Abrasion produces wedge shaped grooves with sharp angles and highly polished dentine surfaces so similarly to attrition, causes a pronounced change in appearance .

The permanent change in appearance of tooth wear can lead to further psychological issues relating to self-image. This is a particularly sensitive issue for patients due to the body dysmorphia they experience which is largely responsible for the onset and development of eating disorders.

Conclusion

After evaluating the different oral complications related to eating disorders, it is clear that there is a range in the extent of the consequences as well as differences in how greatly the eating disorder influences the onset of the oral complication. The most common symptom of eating disorders is general malnourishment due to a reduced dietary intake which can cause several nutrient deficiencies. After analysing the common deficiencies affecting ED patients (calcium, vitamin A, B, C) we can conclude that the effects can be as serious as permanent loss of oral structures. However, a limitation of this conclusion is that every individual will acquire varying eating habits thus we cannot confidently say that all patients will suffer from dental complications caused by nutrient deficiencies. The varying diets mean that not patients will experience different deficiencies and thus, different oral health consequences with varying extremities. Retention of plaque is common among ED patients and this causes both dental caries and periodontal disease. Both of these problems can be avoided with the correct dental care but ED patients are at greater risk due to a higher prevalence of dental plaque. The extent of significance is fairly high as there is an established link between plaque and these complications. Both occur in stages and develop into increasingly serious dental problems e.g periodontal disease develops from gingivitis and dental caries starts in the enamel and dentine before the production of cavities. This decreases the significance because the issues are reversible to a certain extent until they become permanent. Once the development turns into a irreversible dental problem, the extent of the significance of eating disorders is greatly increased. Again, each individual will have differing levels of dental plaque however, overall eating disorders do increase chances of dental caries and periodontal disease. A significant cause of xerostomia is medication, including ones prescribed to ED patients. Although this had an impact, patients with eating disorders are at the same risk of xerostomia as any other individual who has been prescribed certain medications. Therefore, this is a secondary effect of eating disorders on oral health and thus the extent of significance is lower. SIV is common and affects salivary glands and increases acid erosion. Again, erosion is a permanent defect but similarly to tooth decay and periodontal disease, it occurs in stages and develops slowly. Acid erosion increases the likelihood of physical tooth wear such as attrition and abrasion therefore eating disorders significantly impact the chance of patients experiencing tooth wear.

Eating disorders are hard to treat due to the psychologically rooted habits that become hard to break. This means that patients will suffer for long periods up time, commonly years and this means that the extent of impact on dental health is much more significant because the longer an eating disorder lasts, the greater the development of permanent dental problems. If the complications are treatable or improvable then the extent of significance is lower. In this case, a lot of the issues are reversible however, it is likely that they will develop into an irreversible state which means that significance is a lot higher. The stigma around mental health alongside feelings of shame or guilt that a person may experience will prevent them going to the dentist or seeking medical help when the complications are less serious. This means that problems are more likely to develop into permanent damage before a patient seeks help. Additionally, mental health is only being looked into relatively recently and there are many aspects that we are unsure about which means that there are limitations when discussing how significant eating disorders can be on dental health. However, eating disorders have increased in magnitude, incidence and prevalence which means that the subsequent oral complications will also increase in these categories. A greater frequency of incidences increases the significance of the impact of eating disorders on dental health. The most common complications discussed will ultimately lead to the extraction of teeth which cannot be reversed. Therefore, eating disorders do have an overall significant impact on dental health by increasing the likelihood of complications developing. The extent of significance will vary depending on the individual’s lifestyles, therefore we can conclude that the impacts are significant however the extent will vary among individuals.

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