Learn how dental professionals can spot signs of eating disorders and the next best steps forward to getting their patients the help they need.

1. EATING
DISORDERS:
Assessment, Treatment and
Oral Health Management
LisaBerzins, Ph.D.

2. Eating Disorders:
Heterogeneous Populations
• Eatingdisordersareextremedisturbancesinan
individual’srelationshiptofood,weightandbody
image
• Widerangeinleveloffunctioning

3. Eating Disorder Diagnosis:
Comprehensive Assessment
• Dietingandweight
historyincluding
actualanddesired
weight
• Foodrestrictions
• Frequencyofbinging
andpurging
• Exercisehistory
• Ritualisticand
compulsivebehaviors
• Perceivedbodyimage
• Historyofself-
injuriousbehavior
• Historyofshoplifting
• Familyhistory
• Sexualhistory
• Menstrualhistory
• Medicalhistory
• Dentalhistory

4. Anorexia Nervosa:
Diagnosis and Definition
• Restrictionofenergyintakeleadingtosignificantly
lowbodyweight
• Intensefearofbecomingfateventhough
underweight
• Distortedbodyimage
• Excessiveinfluenceofbody weightor shapeon
self-esteem
• Lackofrecognitionoftheseriousnessofthe
currentlowbodyweight

5. Anorexia Nervosa:
Sub-Types
• RestrictingType
• Weightlossisaccomplished
throughdieting,fastingand/or
excessiveexercise
• BingeEating/PurgingType
• Includesepisodesofbinge
eatingand/orpurging (self-
inducedvomitingand/or
misuseoflaxatives,diuretics,
ipecacorenemas)

6. Anorexia Nervosa:
Severity
Mild BMI > 17
Moderate BMI 16-16.99
Severe BMI 15-15.99
Extreme BMI < 15

7. Anorexia Nervosa:
Behavioral Signs and Symptoms
• Fearoffat; drivefor
thinness
• Preoccupationwith
food,weight,body
shape
• Compulsiveexercise
• Perfectionism
• Highlyself-critical
• Lowself-esteem
• Feelingsof
ineffectiveness
• Overly concernedwith
approvalfromothers
• Bodyimagedistortionof
delusionalproportions

8. Anorexia Nervosa:
Physical Signs and Symptoms
• Amenorrhea
• Decreasedlibido
• Bradycardia
• Cardiacarrhythmias
• Osteoporosis
• Loweredblood
pressure
• Loweredbody
temperature
• Lanugo
• Stuntedgrowthifonset
precedespuberty
• AbnormalCTscansin
approximately50%of
cases

9. Anorexia Nervosa:
General Features
• 90%female
• Prevalenceof0.5to1%
amongfemaleadolescents
andyoungadultsusingstrict
criteria;muchhigher
incidenceofsub-threshold
cases
• Onsetusuallybetween14-18
• Prevalencehigherin
industrializedcountries
• Incidenceofminoritycasesin
U.S.isincreasing
• Oftenprecipitatedbydieting
inconjunctionwithstressful
situations
• Comorbidsymptomsof
depressionarecommon
• Obsessive-Compulsive
Disorderin10-13%ofcases

10. Anorexia Nervosa:
Individual Dynamics
• Understandsymptomsasattemptedsolutions
• Compliantoverachievers
• “Goldengirls”-repressangertoavoidcriticism
• Starvationwardsoffintimacy

11. Anorexia Nervosa:
Individual Risk Factors
• Anxietydisordersorobsessionaltraitsin
childhood
• Geneticcomponentseenintwinstudies
• Occupationsandavocationsthatencourage
thinness

12. Anorexia Nervosa:
Family Dynamics and Risk Factors
• Conflictavoidance,concernwithappearances
• Mothersoftenoverly enmeshed,poor boundaries
• Fathersoftenmoredistant
• Inappropriatesexualboundariesmaybepresent
• Increasedriskofanorexiaanddepressionamong
first-degreerelatives

13. Anorexia Nervosa:
Treatment
• Restorepatientstohealthy
weight
• Treatphysicalcomplications
• Nutritionaleducationand
counseling
• Familyeducationand
therapywhenappropriate
• Medicationsforcomorbid
depressionand/oranxiety

14. Anorexia Nervosa:
Treatment (cont’d)
• CognitiveBehaviorTherapy:Correctcore
maladaptivethoughts,attitudesandfeelings
relatedtotheeatingdisorder.
• Behaviortherapy:Self-monitoring
• Mindfulness-basedtherapy:increaseawarenessof
internalstates
• Trauma-informedtherapywhenappropriate

15. Anorexia Nervosa:
Treatment (cont'd)
• Collaborationbetweenpatient,therapistand
dieticianiscritical
• Sensitivitytotrust issuescanhelpdecreasepower
struggles
• Inchronic,treatmentrefractorycases,focuson
qualityoflifeissuesandstabilizationvs.weight
gain.

16. Anorexia Nervosa:
Prognosis
• At minimumof4year followup:
• Goodoutcomein44%ofcases(weightand
menstruationrestored)
• Intermediateoutcomein28%ofcases
• Pooroutcomein28%ofcases(weightlessthan
15%ofthatexpected)

17. Anorexia Nervosa:
Prognosis
• Suicideratesreportedas12per 100,000peryear
(57%higherthaningeneralpopulation)
• Mortalityrateisapproximately5%per decade
(higherthananyotherpsychiatricdisorder)
• Deathmostcommonlyresultsfrommedical
complicationsorfromsuicide.

18. Bulimia Nervosa: Defined
• Recurrentepisodesofbingeeating.Anepisodeofbinge
eatingischaracterizedbybothofthefollowing:
• Eating,inadiscreteperiodoftime(2hoursorless),an
amountoffoodthatismuchlargerthanmostpeoplewould
undersimilarcircumstances
• Asenseoflackofcontrol
• Recurrentinappropriatecompensatorybehaviortoprevent
weightgain.
• Thebingeeatingandcompensatorybehaviorsboth
occur,onaverage,atleasttwiceaweekfor3months.
• Self-evaluationisundulyinfluencedbybodyshapeor
weight

19. Bulimia Nervosa: Severity
Mild Anaverageof1-3episodesofinappropriate
compensatorybehaviorsaweek.
Moderate Anaverageof4-7episodesofinappropriate
compensatorybehaviorsaweek.
Severe Anaverageof8-13episodesofinappropriate
compensatorybehaviorsaweek.
Extreme Anaverageof14ormoreepisodesof
inappropriatecompensatorybehaviorsa
week.

20. Bulimia Nervosa:
Behavioral Signs and Symptoms
• Bingeeating,
disappearanceof
large quantitiesof
food
• Self-inducedvomiting,
frequenttripstothe
bathroom
• Abuseoflaxatives,
diuretics,dietpills,
ipecacand/orenemas
• Preoccupationwith
food,weightand
exercise
• Secretivenesswith
regardtoeating
• Dichotomousthinking
• Poorbodyimage

21. Bulimia Nervosa:
Physical Signs and Symptoms
• Callouseson knuckles
(Russell’ssigns)
• Electrolyteimbalances
• Cardiacabnormalities
• Menstrualabnormalities
• Esophagealtears
• Acidreflux(GERD)
• Kidneydamage
• Pancreatitis

22. Bulimia Nervosa:
Dental Signs and Symptoms
• Erosionofenamelon
teethduetovomiting
whichcanalsocause
toothsensitivity
• Enlargedparotid
glandsdueto
repetitivepurging
• Increasednumberof
cavities
• Halitosisandtooth
discolorationrelated
tostomachacidand
bileinthemouth
• Gumdeterioration

23. Bulimia Nervosa:
Dental Signs and Symptoms

24. How Bulimia Destroys Teeth
https://youtu.be/-baAmEoYKfs?t=10m17s

25. Bulimia Nervosa:
General Features
• 90%female
• Ageofonsetusually
adolescenceoryoung
adulthood
• Prevalenceis1to3%
amongadolescentand
youngadultfemales(using
strictcriteria)
• Typicallywithinnormal
weightoroverweightrange
(BMI >18.5and<30)
• Coexistingdepressionin
40-60%ofcases
• Concurrentanxiety
disordersinover40%of
cases
• Substanceabusepresentin
atleastonethirdofcases
• Personalitydisorders
presentinmorethan50%
ofcases

26. Bulimia Nervosa:
Individual Dynamics
• Binge-purgebehaviorprovidesescapefromself-
awareness
• Attempttoregulatemoodbypurging unwanted
thoughtsandfeelings(“stuffingfeelings”)
• Difficultiesexpressinganger
• Lowself-esteem

27. Bulimia Nervosa:
Risk Factors
• Childhoodobesity
• Earlypuberty
• Socialanxietydisorderandoveranxiousdisorder
ofchildhood
• Weightconcernsandinternalizationofathin
bodyideal
• Depressivesymptoms
• Suicideriskiselevated

28. Bulimia Nervosa:
Treatment
• CognitiveBehaviorTherapyandDialectical
BehaviorTherapyareeffective
• Cessationofpurging behaviorsmitigatesbinge
eatingepisodes
• Normalizationofeating
• Weightstabilization
• Medicalstabilization
• Antidepressantsandmoodstabilizersfor
comorbidsymptoms/disorders

29. Bulimia Nervosa:
Treatment (cont’d)
• Increasedverbalizationoffeelings;assertiveness
skills
• Mindfulnessskillstoincreaseinteroceptive
awareness
• Behaviortherapy:self-monitoring
• Familyeducationandtherapy
• Trauma-informedtherapywhenappropriate
• Substance-relatedtreatmentwhenappropriate

30. Self-Monitoring Example 1

31. Self-Monitoring Example 2

32. Bulimia Nervosa: Prognosis
• Researchsuggeststhatthosewhoreceive
treatmenthave a50-90%reductioninbinge
eatingandpurging.
• Withouttreatment,25-30%improve
spontaneously.
• Individualswithhigherfunctioningandmilder
symptomshaveabetterprognosis.
• Theworstprognosesareassociatedwithsevere
laxativeabusersandcomorbidseverepsychiatric
disorders.

33. Binge Eating Disorder (BED):
Defined
• Recurrentepisodesofbingeeating
• Thebingeepisodesareassociatedwithatleast3
(ormore)ofthefollowing:
1.Eatingmuchmorerapidlythannormal.
2.Eatinguntilfeeling uncomfortablyfull.
3.Eatinglargeamountsoffoodwhennotphysically
hungry.
4.Eatingalonebecauseoffeeling embarrassedabout
howmuchoneiseating
5.Feelingdisgustedwithoneself,depressed,orvery
guiltyafterward

34. Binge Eating Disorder:
Defined (cont’d)
 Marked distress regarding binge eating
 The binge eating occurs, on average, at least
once a week for 3 months.

35. Binge Eating Disorder: Severity
Mild 1-3 binge eating episodes per week
Moderate 4-7 binge eating episodes per week
Severe 8-13 binge eating episodes per week
Extreme 14 or more binge eating episodes per week

36. Binge Eating Disorder:
General Features
• Prevalence of 3.5% of women, 2% of men (most
common eating disorder)
• In weight loss programs, prevalence is at least 30-
40%
• As prevalent among females from racial or ethnic
minority groups as for Whites
• Occurs primarily in normal weight, overweight
and obese individuals.
• Binge eating typically begins in adolescence or
young adulthood but can begin in later adulthood.

37. Binge Eating Disorder:
General Features (cont’d)
• People with BED consume more calories, have more
functional impairment, lower quality of life, more
subjective distress and greater psychiatric morbidity
than weight-matched obese individuals without BED.
• Dieting often follows the development in BED (in
contrast to bulimia in which dieting tends to precede
development).
• Remission rates are higher than for bulimia or
anorexia.
• Tends to run in families.
• Little is known about the development of BED
• Treatment is similar to that of bulimia.

38. What dental professionals can do
if signs are present.
• Approach the issue in a careful, thoughtful manner
that displays concern for the patient’s overall well-
being.
• Do not use labels such as “anorexic” or “bulimic”
which can cause the patient to be defensive.
• Phrase questions so that the patient understands
exactly what you are asking.
• Ask “Do you make yourself throw up?” not “Do you
have an eating disorder?”
• If your patient seems comfortable and is willing to
discuss the issue, use it as an opportunity to talk about
the possible, and sometimes irreversible, dental and
oral health complications of eating disorder behaviors.

39. What dental professionals can do
if signs are present(cont’d)
• If possible, refer the patient directly to an eating
disorder treatment facility in severe cases, or to a
therapist who specializes in treatment of eating
disorders, in milder cases.
• If the patient is defensive, referral to primary care
physician may be most appropriate.
• If the patient is a minor, it may be critical to discuss
your concerns with his or her parents.
• Ideally, you should ask a minor’s permission first.
However, even if your patient is hesitant, expressing
concerns to the parents may ultimately be in his or
hers’ best interest.

40. Eating Disorders Programs in
Connecticut
• Walden Behavioral Care: 781-647-6727
• Guilford
• South Windsor
• Vernon
• The Institute of Living: 860-545-7000
• Hartford
• The Renfrew Center for Eating Disorders:
800-736-3739
• Old Greenwich

41. Thank You!
Contact:
Lisa Berzins, Ph.D.
91 South Main St
West Hartford, CT 06107
(860) 521-2515
Email: lisaberzins56@gmail.com
Website: lisaberzinsphd.com