Eating disorders and oral health: a scoping review

Abstract

Background
Screening and treatment guidance for somatic sequalae of eating disorders typically include specifics such as laboratory testing, observable physical signs, and treatment interventions. Oral health guidance is notably sparse or absent from many guidelines. Often, the only mention of oral health is the potential erosion caused by self-induced vomiting and suggests a referral to an oral health professional. The guidelines generally do not include information about education and training of oral health professionals.

Objective
The objective of this research was to explore the literature on eating disorders and oral health including the effects of eating disordered behaviors on oral health and training of oral health professionals to increase their capacity to recognize and appropriately address clinical care needs of individuals with eating disorders.

Methods
A comprehensive scoping review was conducted to investigate what is known about the relationship between eating disorders and oral health and training provided to oral health professionals in recognition and treatment of individuals with eating disorders. The search was completed using PubMed, Embase, Science Direct, Google Scholar, and the Journal of the American Dental Association.

Results
Of 178 articles returned in the initial search, 72 full texts were read, and 44 were included based on eligibility criteria. The retained articles were categorized thematically into articles related to (1) oral health professional education and training, (2) the oral health effects of eating disorders, and (3) patient experiences of oral health care.

Conclusion
Most of the research on the relationship between eating disorders and oral health examines the impact of eating disordered behaviors. There is a significantly smaller literature on the knowledge and training of oral health professionals related to eating disorders and individuals with eating disorders’ experiences of oral health care. Research on education and training of oral health professionals should be expanded globally, taking into consideration the suitability of interventions for diverse models of oral health education and service delivery. Further, there is an opportunity for eating disorder professionals and professional organizations to improve understanding and care of eating disorders by building relationships with oral health providers and professional organizations in their local communities.

Full text

Presskreischeretal.
Journal of Eating Disorders (2023) 11:55
https://doi.org/10.1186/s40337-023-00778-z
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Journal of Eating Disorders
Eating disorders andoral health: ascoping
review
Rachel Presskreischer1*, Michael A. Prado2, S. Emre Kuraner3, Isabelle‑Maria Arusilor4 and Kathleen Pike5
Abstract
Background Screening and treatment guidance for somatic sequalae of eating disorders typically include specifics
such as laboratory testing, observable physical signs, and treatment interventions. Oral health guidance is notably
sparse or absent from many guidelines. Often, the only mention of oral health is the potential erosion caused by
self‑induced vomiting and suggests a referral to an oral health professional. The guidelines generally do not include
information about education and training of oral health professionals.
Objective The objective of this research was to explore the literature on eating disorders and oral health including
the effects of eating disordered behaviors on oral health and training of oral health professionals to increase their
capacity to recognize and appropriately address clinical care needs of individuals with eating disorders.
Methods A comprehensive scoping review was conducted to investigate what is known about the relationship
between eating disorders and oral health and training provided to oral health professionals in recognition and treat‑
ment of individuals with eating disorders. The search was completed using PubMed, Embase, Science Direct, Google
Scholar, and the Journal of the American Dental Association.
Results Of 178 articles returned in the initial search, 72 full texts were read, and 44 were included based on eligibility
criteria. The retained articles were categorized thematically into articles related to (1) oral health professional educa‑
tion and training, (2) the oral health effects of eating disorders, and (3) patient experiences of oral health care.
Conclusion Most of the research on the relationship between eating disorders and oral health examines the impact
of eating disordered behaviors. There is a significantly smaller literature on the knowledge and training of oral
health professionals related to eating disorders and individuals with eating disorders’ experiences of oral health care.
Research on education and training of oral health professionals should be expanded globally, taking into considera‑
tion the suitability of interventions for diverse models of oral health education and service delivery. Further, there is
an opportunity for eating disorder professionals and professional organizations to improve understanding and care
of eating disorders by building relationships with oral health providers and professional organizations in their local
communities.
Keywords Oral health, Eating disorders, Dental education
Plain English summary
Oral health professionals, including dentists and dental hygienists, are well positioned to observe signs of eating dis‑
ordered behaviors during routine oral health care. To gain an understanding of what is known about the relationship
*Correspondence:
Rachel Presskreischer
rmp2165@cumc.columbia.edu
Full list of author information is available at the end of the article
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

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Presskreischeretal. Journal of Eating Disorders (2023) 11:55
between eating disorders and oral health, we reviewed research studies that discussed any aspect of this relationship.
We identified 44 studies meeting our criteria. Most of the extant research focuses on the impact of eating disorders
on oral health. Smaller portions of the literature discussed education and training of oral health professionals and
patients’ oral health behaviors (including routine oral health care). Educational interventions to increase oral health
professionals’ knowledge of eating disorders and confidence in raising concerns with patients are effective, but
evidence about whether they are being implemented in training programs is lacking. Further, many studies indicated
the need to connect oral health professionals to eating disorder treatment providers. Additional research is needed to
develop guidance and best practices for collaboration between fields.
Background
Eating disorders are serious psychiatric illnesses with
substantial morbidity and mortality, causing signifi-
cant disturbances in somatic health and psychosocial
functioning [1–3]. Research on the somatic effects of
eating disorders indicates that they impact all body sys-
tems and include conditions ranging in severity from
vitamin deficiencies to potentially fatal electrolyte
imbalances and hypoglycemia [4]. Internationally, the
findings from medical research have been translated
into screening and treatment guidelines for provid-
ers by professional organizations in eating disorders,
psychiatry, other medical specialties, and government
bodies [5–10]. While screening and treatment guidance
for many sequalae include specifics such as laboratory
testing, observable physical signs, and treatment inter-
ventions, the guidance related to oral health is notably
sparse or absent from many of the guidelines. Often,
the only mention of oral health is the recognition that
self-induced vomiting may cause dental erosion and
the recommendation for eating disorder professionals
(e.g., therapists, nutrition professionals, nurses, phy-
sicians who treat individuals with eating disorders) to
refer someone who is vomiting to an oral health pro-
vider (OHP) such as a dentist or dental hygienist. Nota-
bly absent is guidance about when to refer patients to
OHPs. is omission is particularly problematic given
that eating disorder professionals report dissatisfaction
with their level of oral health education, and thus tend
to wait until a patient reports complications [11]. Guid-
ance for OHPs on the recognition and clinical care of
someone with an eating disorder is even more sparse.
Across health conditions, it is widely understood
that early identification and intervention leads to bet-
ter health outcomes. e same is true for people with
eating disorders. e paucity of guidance regard-
ing the link between oral health and eating disorders
means that health conditions are not addressed until
the impact is severe. A significant benefit of early inter-
vention is that it decreases the time of untreated ill-
ness [12], which is associated with positive outcomes
such as shorter time to remission [13]. Despite this
opportunity, medical education regarding eating disor-
ders is limited. In a study of 637 U.S. medical education
residency programs in internal medicine, pediatrics,
family medicine, psychiatry, and child and adolescent
psychiatry, 514 did not offer any rotations for eating
disorders. In the 123 programs with rotations, only 42
had a formal, scheduled rotation [14]. A study of Cana-
dian medical residents found that participants had, at
most, 5h of training on eating disorders; those who had
such training reported comfort with screening for and
assessing eating disorders, but a lack of comfort with
medical management. An evaluation of the residents’
knowledge of assessment and treatment of eating dis-
orders supported that they had sufficient knowledge of
assessment practices but were not well-versed in man-
agement and treatment [15]. Medical education in the
United Kingdom is similarly lacking in education about
eating disorders. A 2018 study noted that most physi-
cians receiving < 2h of instruction across 10–16years
of training. Additionally, eating disorders are absent
from the curricula of 20% of medical schools, and < 1%
of students have access to specialty clinical experiences
[16].
Given the particular effects of eating disorders on
oral health, and the opportunity for oral health provid-
ers to play an instrumental role in early detection of
eating disorders, the purpose of this study was to assess
the status of research on clinical implications and pro-
vider education about eating disorders for oral health
providers. Additionally, as the reported rates of eating
disorders education and training are generally low, the
question remains whether such training is provided for
OHPs given the high rates of oral health symptoms that
individuals with eating disorders experience. Presently,
there is limited research on oral health and eating dis-
orders, with existing systematic reviews focusing on
clinical presentation. e primary aim of this study is
to examine the literature on eating disorders and oral
health broadly to capture clinical research (e.g., effects
of eating disordered behaviors on oral health and treat-
ment strategies) and topics such as dental education
and training.
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Presskreischeretal. Journal of Eating Disorders (2023) 11:55
Methods
A scoping review was conducted to identify key concepts,
sources of evidence and research gaps at the intersection
of eating disorders and oral health. Scoping reviews are
appropriate in cases where there is uncertainty about
the breadth of the literature on a topic. Accordingly, the
study was conducted with the methodology and guid-
ance in Peters etal. and from PRISMA [17, 18]. A search
was conducted in Pubmed, Embase, Google Scholar, the
Journal of the American Dental Association and Science
Direct. Search terms included “Eating Disorder”; “Eat-
ing Disorders”; “Disordered Eating”; “ED”; “EDs”; “ED’s”;
“Anorexia”; “AN”; “Bulimia”; “BN”; “EDNOS”; “Binge
Eating Disorder”; “Restrictive Food Intake Disorder”;
“ARFID”; “Rumination Disorder”; “Other Specified Feed-
ing or Eating Disorder”; “OSFED”; “Unspecified Feed-
ing or Eating Disorder”; and “UFED”. ese terms were
combined with the additional terms “Dentist”; “Den-
tists”; “Dental”; “Dentistry”; “Oral Hygiene”; “Hygienist”;
“Hygienists”; “Oral Health”; “Caries”; “Cavity”; “Cavities;
Teeth”. MeSH and Emtree terms included “Feeding and
Eating Disorders”[Mesh]) AND “Oral Health”[Mesh]
Emtree terms: ‘dentistry’/exp/mj AND ‘eating disorder’/
exp/mj. Articles were eligible for inclusion if they were
written in or translated into English, published in peer-
reviewed journals, and had a publication date after the
year 2000. e year 2000 was selected for three reasons.
First, to capture research from the current century. Sec-
ond, knowledge of eating disorders had spread beyond
the mental health fields such that it would be feasible to
capture research in a broader range of disciplines. Finally,
the expansion in internet use at the turn of the century
and growth technology would ensure that we were identi-
fying current trends in education and training. Full inclu-
sion and exclusion criteria are provided in Table1. Two
members of the study team reviewed all studies indepen-
dently and any disagreements were discussed to reach
consensus. For each article meeting inclusion criteria,
data were extracted for: (1) country in which data were
collected, (2) primary study aim, (3) study design, (4)
included eating disorder diagnoses, and (5) findings.
Results
An initial 178 articles were identified from the search
terms (Fig. 1). After removal of duplicates, 147 titles
and abstracts were screened for inclusion. A total of 93
articles were sought for retrieval, with 21 not retrieved
due to a lack of full-text availability. Of the remaining
72 articles, 20 were excluded as not original research, 4
lacked an English language version, and 3 were excluded
because they were not relevant to oral health and eating
disorders. Forty-four studies were retained for inclu-
sion (Table 2). Of these 44 studies, seventeen related
specifically to oral health professionals [19–35], twenty
addressed the impact of eating disorders on oral health
[36–55], and seven focused on patient experiences and
perspectives [56–62].
Oral health professional education andtraining
e 17 articles about oral health professionals fell into
three overarching categories: knowledge, education, and
practices.
Seven of the articles assessed OHPs’ knowledge of
the oral health signs of eating disorders, symptoms of
eating disorders, how to raise concerns with a patient,
and where to refer a patient for treatment if necessary.
Of these seven articles three studies included dentists
and dental hygienists [19, 27], three included dentists
only [26, 28], one included hygienists only [22], and one
included a random sample of dental practices. All stud-
ies were conducted in the United States except one which
was conducted in Norway [33]. All seven studies indi-
cated that OHPs lacked sufficient knowledge of eating
disorders and limited clinical experience. Of those who
were aware of oral health signs and symptoms, many
reported not knowing how to address their observations
Table 1 Inclusion and Exclusion Criteria
Inclusion criteria Exclusion criteria
Year of publication 1/1/2000—Present Prior to 1/1/2000
Language English, or English translation Non‑English, no English translation
Article type Original research published in peer‑reviewed journals Articles not peer‑reviewed, prior
systematic reviews/evidence reviews,
commentaries, dissertations, white
papers
Study population Individuals of any age and gender with a diagnosed with or at risk for DSM IV
or DSM 5 eating disorder Individuals without eating disorders
Focus of article Topics relating to oral health/oral healthcare and eating disorders Oral health topics unrelated to eating
disorders, eating disorder related top‑
ics not relevant to oral health
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Presskreischeretal. Journal of Eating Disorders (2023) 11:55
with patients. Most OHPs did not refer patients for eval-
uation and treatment of their eating disorder, and when
they did it was usually to primary care physicians rather
than mental health providers.
Additional studies addressed education provided to
oral health students about eating disorders and inter-
ventions to improve student and provider knowledge.
e study populations included deans of dental schools
and directors of dental hygiene programs [25], dentists,
hygienists and students in dental and dental hygiene
programs [23], and dental and dental hygiene students
[20, 21, 24, 30]. e primary findings from these studies
indicated that dental and dental hygiene students receive
minimal instruction (between 17 and 35 min) in eating
disorders [20, 25] and that interventions to provide edu-
cation about eating disorders and their related effects on
oral health can improve OHPs knowledge and capacity to
intervene in patient care. DeBate etal. [20] study lever-
aged intervention mapping to design and test an online
intervention to improve OHP student’s awareness of the
impact of eating disordered behaviors on oral health
and treatment options available to people with eating
Fig. 1 PRISMA flow diagram of study selection. From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA
2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. https:// doi. org/ 10. 1136/ bmj. n71
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Presskreischeretal. Journal of Eating Disorders (2023) 11:55
Table 2 Articles included in the scoping review
Author (Year) Country Study aim(s) Study design Included ED diagnoses Findings
Back‑Brito [36] Brazil To evaluate fungal microflora in the oral cavity Matched case–control
N = 59 AN, BN The identification of uncultured microflora
species first reported in this study was also
observed in dental biofilm from the ED group
Boillot [37]
France To determine whether generalized reduced
periodontium and dental erosion in women
with EDs are associated with systemic biologi‑
cal parameters
Secondary analysis of the PERIOED case–con‑
trol study
N = 45 Female
AN, BN Serum ferritin levels together with age may
be helpful in screening patients with ED for
adequate referral to a dentist
Burgard [19]
USA To better understand how dental practitioners
identify, counsel, and refer patients with EDs Survey
N = 123 N/A Approximately 50% of respondents reported
evaluating a patient with an ED in the past
year and most spoke to the patient or a parent.
Some respondents do not raise concerns due
to ambiguity of dental findings or not knowing
what to say. Less than 1/3 referred patients to
additional care, and those who did, referred
almost exclusively to primary care
Conviser [56]
USA To understand oral health behaviors after
purging and patient perspectives on barriers
to patient‑initiated discussion of EDs with
OHPs
Cross‑sectional survey
N = 201 BN Participants had high levels of concern about
their oral health and a high incidence of oral
health problems, but less than one third
considered their OHPs to be the most helpful
source of oral health information
De Moor [38] Belgium To present a case of a female patient with a
history of AN, followed by BN that resulted in
dental destruction over a 5‑year period
Case study
N = 1 AN, BN Early erosions were particularly limited to the
lingual surfaces of the maxillary anterior teeth
and occlusal surfaces of the maxillary premolars
and mandibular posterior teeth. Resin restora‑
tions have been used to restore teeth with
erosion and those demonstrating dentine
hypersensitivity
DeBate [27]
USA To determine the knowledge among dentists
and dental hygienists concerning the oral and
physical manifestations of EDs
Randomized cross‑sectional study
N = 945 N/A Most respondents had low knowledge of clini‑
cal findings associated with EDs, with hygienists
more likely to identify oral manifestations.
There was generally low knowledge of physical
manifestations of EDs
DeBate [26]
USA To explore beliefs, attitudes, and experiences
of general dentists regarding ED‑specific
secondary prevention behaviors
90‑min focus groups
N = 21 N/A Curriculum development, policies, and prac‑
tices are places for intervention to support and
sustain secondary preventive clinical behaviors
among dentists
DeBate [22]
USA To explore readiness and capacity for integra‑
tion of oral health and mental health services Cross‑sectional survey
N = 378 N/A Only 18% of the sample reported referring
patients to clinical eating disorder care. It is
important to improve capacity for secondary
prevention and self‑efficacy
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Presskreischeretal. Journal of Eating Disorders (2023) 11:55
Table 2 (continued)
Author (Year) Country Study aim(s) Study design Included ED diagnoses Findings
DeBate [28]
USA To assess sex differences among dentists per‑
taining to current behaviors and behavioral
beliefs about EDs
Cross‑sectional survey
N = 350 N/A Respondents had an overall low level of
secondary ED prevention practices. Disso‑
nance was observed between dentists about
reported high levels of perceived benefits of
prevention practices and self‑efficacy and the
modest number of dentists currently engaged
in secondary prevention practices. More female
dentists reported engagement in prevention
practices than their male counterparts
DeBate [25]
USA To assess the breadth and depth of ED spe‑
cific comprehensive and primary care instruc‑
tion in dental and dental hygiene curricula
Cross‑sectional survey
N = 114 N/A The findings indicate an increased inclusion
of ED training in programs from a previous
study. More dental hygiene programs include
ED education than dental programs. There is a
significant lack of training in communication
with patients exhibiting signs of EDs
DeBate [23]
USA To develop and evaluate a program to
improve secondary prevention of EDs in oral
health providers
Two phase study:
Phase 1: focus groups, N = 41
Phase 2: pilot evaluation, N = 64
N/A There was a statistically significant change from
pre intervention to post intervention across
variables. Participants found training useful,
provided more information than generally avail‑
able, and was appropriately tailored
DeBate [21]
USA To develop and evaluate a framework aimed
at oral healthcare providers to engage in
active secondary prevention of EDs
Group randomized controlled trial
N = 18 N/A There was significant improvement from
pre‑intervention to post‑intervention in the
intervention group compared to the control
group on knowledge of EDs and oral findings,
skills‑based knowledge and self‑efficacy
DeBate [24]
USA To test whether an interactive, web‑based
training program is more effective than
an existing, latest e‑learning program at
improving oral health students’ knowledge,
motivation, and self‑efficacy to address signs
of disordered eating behaviors with patients
Group randomized controlled trial
N = 18 classes, 317 students N/A Post‑test differences between groups showed
greater improvement among intervention
participants in three domains compared to the
alternative program. The findings suggest that
interactive training programs may be better
than e‑learning
DeBate [20]
USA To use IM to develop a theory‑ and evidence‑
based intervention to increase the capacity of
oral health providers to engage in secondary
prevention of EDs
Prospective group‑randomized controlled trial
N = 27 N/A The systematic IM process resulted in an
innovative theory and evidence‑based training
curriculum that highlighted the importance
of oral‑systemic health and associated clinical
behaviors that can positively impact the overall
health of persons with ED behaviors
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Table 2 (continued)
Author (Year) Country Study aim(s) Study design Included ED diagnoses Findings
DiGioacchino [29] USA To build a framework for the development
of effective programming to increase the
proportion of dental practitioners involved in
secondary and tertiary prevention and case
management
Pen and paper survey
N = 45 N/A The findings indicate that dentists and hygien‑
ists were not aware of complications/manifesta‑
tions of EDs. There was a lack motivation to take
action, with identified barriers to action of dif‑
ficulty speaking to patients about concerns of
ED and lack self‑efficacy in corresponding with
primary care providers or referral processes
Dynesen [39] Denmark To study if BN has an impact on salivary gland
function, if salivary gland function relates to
dental erosion in persons with BN, and if den‑
tal erosion in BN is related to behavior regard‑
ing diet, purging, and duration of the ED
Case–control, questionnaire and dental exam
N = 40 BN The BN persons had impaired unstimulated
whole saliva (UWS), mainly owing to medica‑
tion; increased feeling of oral dryness; and
more dental erosion. Dental erosion was related
to the duration of ED, whereas no effect of
vomiting frequency or intake of acidic drinks on
reduced UWS was observed
Dynesen [57] Denmark To uncover knowledge, experience, and atti‑
tudes of oral health and oral health behavior
among persons with EDs
Cross‑sectional, electronic questionnaire
N = 260 AN, BN, atypical AN The participants with EDs were, in general,
concerned about their teeth. Some feared that
they had severe and irreversible tooth damage,
and many were overly occupied with oral
hygiene procedures. Some of the participants
had good experiences in communicating with
the dentist and wanted the dentist to address
EDs in the clinic. However, participants with
less‑positive experiences highlighted a need for
dentists with specialized knowledge of EDs and
communication skills, focusing on an empathic
approach from the dentist
Emodi‑Perlman [40]
Israel To compare the prevalence of psychologic,
dental, and temporomandibular disorder
signs and symptoms between young women
suffering from chronic EDs and a control
group of age‑matched, healthy women, and
to evaluate the impact of frequent vomiting
on these signs and symptoms among the ED
group
Clinical examination and self‑administered
questionnaires
N = 129
AN, BN, EDNOS Women with EDs presented higher general
muscle sensitivity than healthy women of the
same age, as well as higher emotional and
psychologic distress. This may suggest a higher
susceptibility of women suffering from ED to
suffer also from myofascial pain than healthy
subjects. Most differences did not reach statisti‑
cal significance, probably because of the small
number in each group and the application of
the Bonferroni correction for multiple testing.
However, the results clearly indicate some
disparity between the 2 groups
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Table 2 (continued)
Author (Year) Country Study aim(s) Study design Included ED diagnoses Findings
Frimenko [30] USA Assess dental students’ ED and interpro‑
fessional care (IPC) related educational
experiences, perceptions of preparedness
for ED‑related communication with patients
and providers, and attitudes related to an IPC
approach to EDs
Paper and web‑based survey
N = 596 N/A 3rd and 4th year students felt educated about
basic ED related issues (signs, symptoms,
systemic effects) but not about ED treatment
protocol and referral protocol. Reported asking
about physical health and referring but not
mental health and rarely referred to mental
health provider. Did not feel prepared to com‑
municate with patients and health care provid‑
ers from other disciplines about mental health
Galindo [31]
USA To describe the reconstruction of a maxillary
anterior segment using immediate implant
placement and immediate implant load‑
ing techniques, aided by computer‑ guided
implant treatment software and stereolitho‑
graphic models and surgical templates, in a
patient with a history of ED
Case study
N = 1 BN This clinical report describes rehabilitation
using implant‑ supported FPDs on immedi‑
ately placed and immediately loaded dental
implants, aided by computer‑guided implant
treatment software, stereolithographic models,
and surgical templates, of a partially dentate
patient affected by EDs
Giraudeau [32] France To assess the benefits and feasibility of
providing a systematic dental examination
via telemedicine for all patients in the ED day
hospital
Two phase study: virtual visit and analysis
N = 50 AN, BN Dental erosion was found in 92% of the
patients, and 50% had at least one tooth with a
BEWE score of 2 or 3
Hermont [41] Brazil To compare the occurrence of tooth erosion
and dental caries in adolescents with and
without risk behavior for EDs
Controlled cross‑sectional study
N = 1,203 N/A Severe risk behavior for EDs was significantly
associated with tooth erosion, but not with
dental caries
Imai [42]
Japan To present a case of necrotizing sialometa‑
plasia (NS) accompanied by significant dental
erosion of the maxillary teeth of the palatal
surfaces owing to chronic self‑induced
vomiting
Case study
N = 1 N/A Temporary worsening of binging‑purging
before the development of NS would likely
have led to an increase in traumatic stress and
chemical exposure of the palate. Iron deficiency
hypochromic anemia could compromise the
steady supply of oxygen to the palate locally
affected by frequent abnormal eating behav‑
iors. These systemic and local factors might trig‑
ger irreversible ischemic changes in the palatal
salivary gland tissues for a short time
Johansson [43] Sweden To compare the oral health status of patients
with EDs, with sex‑ and age‑matched controls,
with a view to identify self‑reported and
clinical parameters that might alert the dental
healthcare professional to the possibility of
EDs
Matched case–control,
questionnaire and dental exam
N = 108
AN, BN, EDNOS Self‑reported presence of dental problems was
significantly more common among ED patients
compared with controls, and the presence of
oral problems on a daily basis was reported by
13% of ED patients compared with only 2% of
the controls. The reporting of symptoms on a
weekly or daily basis was about two‑ to three‑
fold higher in ED patients than in controls
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Table 2 (continued)
Author (Year) Country Study aim(s) Study design Included ED diagnoses Findings
Johansson [33] Norway To investigate knowledge, attitudes and
clinical experience about patients with EDs
among Norwegian dentists
Questionnaire sent via mail
N = 1726 N/A The dentists in this study reported limited
clinical experience and insufficient knowledge
regarding EDs. There is therefore a need to
increase both undergraduate and continuing
education in this field
Johansson [59] Sweden To investigate diet, oral hygiene habits and
awareness of possible negative factors for
oral health, as well as utilization of dental
care in ED patients during periods when self‑
perceived ED status was "relatively good" vs.
"relatively bad”
Case–control
N = 108 AN, BN, EDNOS The conclusions drawn from this study are that
ED patients presents a number of dietary and
other types of behavior that are potentially
harmful for their general and oral health. For a
more accurate detection of these activities, it is
important that the patient report on the behav‑
iors both when she/he is in a relatively good as
well as being in a more active disease state
Johansson [58] Sweden To investigate the behavior in ED patients
with self‑induced vomiting in relation to
binge eating, oral health, and dental care
Cross‑sectional questionnaire
N = 17 AN, BN, EDNOS Variation in frequency and duration of episodes
of self‑induced vomiting indicate that the
consequences for oral health will vary and be
affected by the specific compensatory behavior
executed in patients suffering from an ED. The
dental team should be made aware of the likely
detrimental effects of binge eating and vomit‑
ing on oral health and the large variations of
behavior and the cyclical nature of the disease
Lee [34]
Korea To present case studies that describe the
prolonged food restriction of two girls due to
the wearing of dental braces in which patho‑
logical eating behaviors and serious medical
conditions emerged
Case study
N = 2 ARFID, AN Pathological eating problems may occur in
association with orthodontic treatment dur‑
ing adolescence. To prevent serious eating
problems that are related to fatal physical
conditions, a collaborative assessment between
the orthodontist, the patient, the family, and
a psychiatrist about the earliest signs of EDs is
required
Lifante‑Oliva [44] Spain To study oral complications in females with
EDs Descriptive study
N = 17 ED diagnoses in DSM IV A significant alteration in oral tissue occurs; this
has an adverse impact on oral health, produc‑
ing an accumulation of local irritants which
favor the appearance of oral diseases
Lourenço [45] Portugal To evaluate the oral health status and orofa‑
cial problems in a group of outpatients with
EDs
Case–control, questionnaire and dental exam
N = 33 AN, BN Outpatients with EDs were found to present a
higher incidence of oral‑related complications
and an inferior oral health status, compared to
gender‑ and age‑matched controls
Lundgren [46] Denmark To determine if nocturnal eating is related to
tooth loss in a large, epidemiologic sample Longitudinal, case–control design
N = 2217 NES The study findings show that nocturnal eating
does have oral health implications, supporting
previous findings that nocturnal eating, but not
evening hyperphagia, is associated with tooth
loss, periodontal disease and active tooth decay
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Presskreischeretal. Journal of Eating Disorders (2023) 11:55
Table 2 (continued)
Author (Year) Country Study aim(s) Study design Included ED diagnoses Findings
Otsu [47]
Japan To investigate the relationship between the
severity of dental erosion and the vomiting
behavior and regular dietary habits of patients
with EDs
Oral assessment for dental erosion, standard‑
ized interview
N = 71
AN, BN, EDNOS While self‑induced vomiting is the main cause
of dental erosion in ED patients, the erosion
severity may be affected by behavior when
inducing vomiting or by routine consumption
of certain foods and beverages. Addressing
these factors may help prevent severe dental
erosion in patients who chronically induce
vomiting
Pallier [48]
France To evaluate dental and periodontal health
in anorexia nervosa and bulimia nervosa
patients
Case–control full‑mouth exam and review of
oral hygiene behaviors
N = 140
AN, BN, EDNOS The study found a significantly different oral
disease profile among patients as a function of
ED diagnosis type. AN patients presented worse
periodontal conditions with higher dental
plaque accumulation, gingival inflammation
and clinical attachment loss than BN patients.
AN patients also reported brushing their teeth
more frequently than BN patients (p < 0.01).
The findings suggest an adaptation to the
prevention of oral diseases according to the ED
diagnosis type
Paszynska [50] Poland To evaluate stimulated and resting salivary
flow rate and the activity of the following
enzymes in both types of saliva: amylase,
aspartate amino transferase (AST), ala‑
nine amino transferase (ALT), collagenase,
lysozyme, peroxidase, serine and acidic pro‑
teases, and trypsin in persons with AN and to
compare them with those of healthy controls
Case–control observational
N = 66 AN Reduced salivary flow might be one indicator of
anorexia. Despite starvation and anorexia devel‑
opment, salivary key enzymes show physiologi‑
cal activity. This indicates a partial adaptation
of the organism to severe conditions during
malnutrition
Paszynska [49] Poland To establish the oral status regarding caries
incidence, tooth wear, gingival inflammation,
and oral hygiene levels among severely ill
adolescent inpatients diagnosed with AN
Case–control cross‐sectional survey, clinical
examination of dental wear
N = 220
AN Study findings indicate impaired dental and
gingival conditions in young people with
anorexia. Considering AN’s potential role in
oral health, it is essential to monitor dental
treatment needs and oral hygiene levels in their
present status to prevent forward complica‑
tions in the future
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Presskreischeretal. Journal of Eating Disorders (2023) 11:55
Table 2 (continued)
Author (Year) Country Study aim(s) Study design Included ED diagnoses Findings
Rangé [51]
France To design a questionnaire to identify risk
factors and symptoms of oral diseases and to
test its reliability as a self‑report form among
people with AN
Self‑report questionnaire, face‑to‑face repeat
questionnaire administered by dentist
N = 69
AN The study authors developed and tested a
questionnaire that identifies risk factors and
symptoms of oral diseases in anorexia nervosa.
The 26‑item form of the questionnaire (long
version) is moderately reliable as a self‑reported
form. A short version of the questionnaire,
including the 10 most reliable items, is recom‑
mended for oral risk assessment in patients
with anorexia nervosa. The clinical value of the
self‑administered questionnaire remains to be
evaluated
Sales‑Peres [52]
Brazil To evaluate the prevalence, distribution, and
associated factors of dental wear among
patients with EDs
Case–control
N = 60 AN, BN Dental wear was similar for both groups; the
experimental group presented more moderate
wear in molars. The etiological factors of tooth
wear related with dental wear were biting
objects and pain in temporomandibular joints
Sharifian [60] Finland To evaluate the associations between dental
fear and EDs and BMI, with respect to age,
gender, educational, sector, attitude to food,
and mental well‑being among a representa‑
tive sample of Finnish university students
Cross‑sectional secondary analysis of data
from University Student Health Survey
N = 3090
No diagnosis, AN, BN, Other Among the Finnish university students BMI in
males and problems of mental well‑being in
females were positively associated with high
dental fear. The results of this study support
possible common vulnerability factors that
dental fear and other psychological disorders
may share
Shaughnessy [53] USA To evaluate the dental and periodontal health
of adolescents and young women with
restrictive anorexia nervosa, and the relation‑
ship between bone mineral density assessed
by dual energy X‑ray absorptiometry (DXA)
and dental radiographs
DXA bone mineral density measurements,
comprehensive dental examination
N = 23
AN Despite subnormal DXA measurements in
most patients, essentially all adolescents had
a normal dental examination. Dental provid‑
ers should be cognizant of the fact that many
patients with EDs may not display the “classic”
findings reported in the literature
Sirin [61]
Turkey To evaluate the levels of dental fear and
anxiety in women with EDs scheduled for oral
surgery
Case–Control
N = 562 AN, BN, EDNOS The findings indicate that the ED group had
greater levels of dental anxiety and fear than
the non‑ED dental patients and randomly
selected individuals from a nonclinical environ‑
ment. In addition, significant differences were
found between the AN subtypes and the pres‑
ence or absence of purging behavior
Strużycka Poland [55] To investigate the prevalence of erosive
lesions and related risk factors in the popula‑
tion of 18‑year‑old young adults in Poland
Cross‑sectional clinical assessment of denti‑
tion, questionnaire
N = 1869
N/A In this study, 1.4% reported EDs and preva‑
lence of erosion in anterior region significantly
associated with EDs. Roughly half of those who
had EDs had varying intensity of erosion type
damage to the teeth
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Presskreischeretal. Journal of Eating Disorders (2023) 11:55
Table 2 (continued)
Author (Year) Country Study aim(s) Study design Included ED diagnoses Findings
Turhani [35] Austria To address complications and complex man‑
agement of an active bulimic patient treated
with dental implants and elucidate partial
failures resulting in mandibular fracture
Case study
N = 1 BN Dental implant in osteopenic bone predisposes
atrophic mandibles for infection and subse‑
quent fracture. Risk/benefit ratio of endosse‑
ous implants is not favorable long term, thus
people with EDs need to be diligently selected
and fully informed of the hazards underlying
this type of rehab
Willumsen [62] Norway To investigate the prevalence of dental fear,
dental attendance, reports of dental erosion,
and frequency of informing dentists about
eating disorders in women with EDs
Questionnaire via mail
N = 371 AN, BN, BED The survey supports the hypothesis that
women with EDs have higher levels of dental
fear than women in the general population.
The present study further indicates that dental
fear is a risk factor for poor dental health in ED
patients
Ximenes [54] Brazil To examine the prevalence of oral alterations
related to EDs and associated factors Cross‑sectional self‑report questionnaires,
dental examination
N = 650
N/A Significant associations were observed in
mucositis, cheilitis, hypertrophy of salivary
glands, and dental erosions. The prevalence
of adolescents at risk for EDs was of 33.1%,
according to EAT‑26 and 1.7% (high scores) and
36.5% (medium scores) in BITE. All these factors
showed significant relation to EDs
ED Eating disorder, AN Anorexia nervosa, BN Bulimia nervosa, BED Binge eating disorder, EDNOS Eating disorder not otherwise specied which included BED (replaced with other specied feeding or eating disorder and
unspecied feeding or eating disorder in DSM-5), NES Night eating syndrome, ARFID Avoidant/restrictive food intake disorder, DSM-IV The Diagnostic and Statistical Manual of Mental Disorders—4th edition
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Presskreischeretal. Journal of Eating Disorders (2023) 11:55
disorders [20]. e study demonstrated positive benefit,
high student satisfaction with the program, and student
interest in retaining access to the educational materials
provided in the intervention.
e final category of articles relates to specific prac-
tices of OHPs when working with patients who have eat-
ing disorders. Of the four articles in this category, three
are case studies providing insight into procedures OHPs
used to address specific effects of eating disorders on
oral health. In a 2014 paper, Lee etal. present two cases
of adolescents who restricted food intake as a result of
wearing braces that led to hospitalization for eating dis-
orders [34]. e two other case studies describe proce-
dures for treating oral health conditions in patients with
longstanding bulimia nervosa [31, 35]. In both cases the
eating disorder had significant effects on the patient’s
teeth, including placement of implants or removable
prosthesis, addressing both functional and aesthetic con-
cerns. A final study examined the integration of tele-den-
tistry consultations into eating disorder day treatment
to screen for oral health conditions and prevent dental
erosion [32]. e article findings suggest that the use of
tele-dentistry in an established eating disorder treatment
program may provide advantages such as targeted evalu-
ation of the oral health of individuals with eating disor-
ders and an opportunity to establish oral health care for
patients who may otherwise not have access to or not
seek care.
Eects ofeating disorders onoral health
e largest numbers of articles generated by the scoping
review focused on the oral health effects of eating dis-
order behaviors. One study examined the prevalence of
erosive lesions in a cross-section of Polish 18-year-olds
and found that lesions were significantly associated with
eating disorders [55]. Eleven of the studies used case–
control designs to compare oral health findings between
people with/at risk for eating disorders and healthy con-
trols/those not at risk. An additional six studies described
oral health effects and risk behaviors in patients with
diagnosed eating disorders [41, 44, 47, 51, 53, 54]. Find-
ings from these studies indicate negative effects of eat-
ing disorders on oral health including tooth erosion,
increased size of salivary glands, and gingival recessions
at higher rates than control groups. One study evaluated
dental conditions and oral health behaviors (e.g., fre-
quency of brushing) and noted differences in the presen-
tation of both between people with anorexia nervosa and
bulimia nervosa [48]. Additional findings in these stud-
ies showed increased self-reported oral health problems
in individuals with eating disorders compared to those
without [43], and a higher presentation of general muscle
sensitivity potentially suggesting higher susceptibility to
myofascial pain than healthy subjects [40].
Two articles described the impact of eating disorder
behaviors in individual cases. One study described a
patient who’s self-induced vomiting led to necrotizing
sialometaplasia (a benign ulcerative lesion due to tissue
death of the salivary glands) and significant dental ero-
sion [42]. e other case study described dental evalu-
ation and treatment of a patient over a 6-year period,
noting worsening oral health symptoms and denial of an
eating disorder [38]. At the appointment 6 years from the
original appointment, she shared her longstanding eating
disorder with her OHP and her initial reluctance to con-
firm their concerns.
A final study designed and tested a questionnaire to
identify oral health risk factors and symptoms in indi-
viduals with anorexia nervosa. A 26-item questionnaire
was assessed and found have moderate reliability when
administered as a self-report form. e ten most reli-
able items from the original questionnaire were recom-
mended as a risk assessment in patients with anorexia
nervosa [51].
Patient practices andexperience oforal health care
e remaining seven articles evaluated dental fear and
anxiety, oral hygiene knowledge and attitudes, and oral
health behaviors in individuals with or at-risk-for eating
disorders. ree articles identified elevated dental fear
and anxiety among individuals with or at risk for eat-
ing disorders compared to those without [60–62]. ese
study samples were Finnish university students, Norwe-
gian women with diagnosed eating disorders recruited
from a self-help organization, and Turkish individuals
with and without eating disorders about to undergo oral
surgery. e methods used to identify patients with or at
risk for an eating disorder varied across studies, as did
their assessments to measure dental fear and anxiety.
Two papers evaluated oral health concerns, sources of
information about oral health effects of eating disorders,
and willingness to see OHPs in people with eating disor-
ders [56, 57]. Both articles found that participants were
concerned (with high proportions expressing significant
concern) about the impact of their eating disorder on
their oral health. For sources of information, Conviser
et al. found that, of participants who sought informa-
tion about how to minimize damage from purging, 84%
found the internet to be one of the most helpful sources
of information, whereas only 29% included OHPs as
one of the most helpful. In Dynesen etal. research, 70%
obtained information about oral health complications
from media sources (e.g., internet, television) compared
to 24% from a dentist.
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Presskreischeretal. Journal of Eating Disorders (2023) 11:55
Conviser etal. and Dynesen etal. also evaluated oral
care behaviors following self-induced vomiting. Con-
viser etal. asked whether participants rinsed the mouth
with water or a mouth rinse (84%) or brushed their teeth
immediately after (33%) purging. Dyneson et al. study
summarized the findings of participants’ oral health
behaviors following SIV as neutralizing acid in the mouth
(34%) and avoiding toothbrushing (29%). Both studies,
along with Wilumsen etal. [62], and Johanssen etal. [58]
found that most participants had not told an OHP about
their eating disorder. Johanssen etal. reported that only
6% of participants disclosed their eating disorder, with
29%, 32%, and 39% disclosing in Conviser, Dynesen, and
Willumsen respectively.
Additionally, Dynesen, Willumsen, and Johanssen
asked participants about frequency of visits to an OHP.
Dynesen etal. framed the question in terms of frequency,
with 33% reporting visiting the dentist more than twice
per year [57]. Willumsen etal. asked about the date of
participants’ last dental treatment—with 87% having seen
a dentist in the last 2 years [62]. Johanssen etal. found
that 71% attended “regular dental visits” but did not spec-
ify a time frame. However, the average time between vis-
its for people attending any dental appointments in the
study was 14months [58].
e last study examined differences in behaviors in
individuals with eating disorders at different clinical pres-
entations in their eating disorders. ey compared par-
ticipant responses when symptoms were relatively absent
(defined as ED-good) and when they were more “active”
or highly symptomatic (defined as ED-bad) [59]. ey
found that behaviors associated with different states of an
individual’s eating disorder posed differential risks to oral
health. Compared to health controls, ED-good was pre-
dicted by the variables: higher intake of caffeinated bev-
erages, and lower intake of regular (non-diet) soft drinks.
Predictive variables of ED-bad were: lower frequency of
lunch, and lower intake of sweet biscuits. A key takea-
way from the study is that between ED-good and ED-bad
states, an individual’s behaviors pose different risks to
oral health.
Discussion
is scoping review investigated the state of evidence
about oral health and eating disorders. In addition to lit-
erature on the oral health sequalae of eating disorders,
included articles addressed (1) eating disorder knowledge
and education of OHPs, (2) interventions OHPs use to
treat effects of eating disorders, and (3) patient attitudes
and behaviors related to oral health care. Across the dif-
ferent categories of studies, a consistent finding was that
OHPs do not receive sufficient education and training
to address eating disorders in practice—inhibiting early
identification, treatment, and referral.
OHPs’ insufficient knowledge of eating disorders is
evidenced by an absence of or minimal educational con-
tent on eating disorders and lack of clinical exposure to
patients with eating disorders in training programs. e
insufficient training received in OHP training programs
is similar to medical training programs [14–16, 63].
e factors that impacted OHP’s ability to identify and
comfort with treating patient with eating disorders was
associated with their exposure to clinical cases during
training and working with a clinician who had a particu-
lar interest in eating disorders, factors also associated
with physicians’ ability to identify and treat patients with
eating disorders [63].
Research examining methods to educate OHPs
about eating disorders found promising results. Knowl-
edge about eating disorders and their presentation was
increased, and the interventions were considered accept-
able to participants. While both a static e-learning train-
ing and an interactive training improved participants’
knowledge of eating disorders, the interactive training
was superior at reducing OHPs’ perceived barriers to
secondary prevention, increasing perceived benefits of
secondary prevention, and increasing perceived self-
efficacy to perform secondary prevention behaviors [24].
e small body of research on educational programs
warrants further study to examine the transferability of
these interventions into non-U.S. oral health training
programs. Additionally, uptake of these educational pro-
grams by dental and dental hygiene programs will be an
important are for additional research.
One major area of note across the included studies was
the assertion that OHPs need to be connected to eating
disorder professionals. No studies were identified that
examined mechanisms for connecting OHPs and eating
disorder professionals. e eating disorders field has an
opportunity to build relationships with local and national
oral health provider organizations and with local provid-
ers to increase awareness of referral resources and offer
support to OHPs who may be among the first providers
to observe an eating disorder. Increasing OHPs aware-
ness of resources for eating disorder treatment and eating
disorder treatment providers’ knowledge of oral health
risks and referral resources presents an opportunity for
research into methods to incorporate OHPs in eating dis-
order treatment teams. e clearly stated need for these
relationships and the noted lack of research indicates an
important area of study for researchers across the globe.
A small portion of the research in this review examined
eating disorder patients’ oral hygiene behaviors and feel-
ings about oral health procedures. e findings in these
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Presskreischeretal. Journal of Eating Disorders (2023) 11:55
studies indicate that many individuals do not disclose
their eating disorder to OHPs and may engage with oral
health care less frequently than clinically recommended.
Future research should evaluate whether and how eat-
ing disorder treatment professionals can contribute to
patient engagement with oral health care. In addition
to the potential for engagement between eating disor-
der professionals and OHPs, there is an opportunity for
eating disorder professionals to encourage patients to
disclose to OHPs and to address fear and anxiety about
oral health procedures. ere is also an opportunity to
examine the ways that OHPs can be formally included in
the American Psychiatric Association practice guidelines
for the treatment of eating disorders as members of the
multi-disciplinary research team—and whether doing so
increases engagement with OHPs.
A final note on the findings of this scoping review is
that the majority of work on oral health and eating dis-
orders is on the oral health sequalae of eating disordered
behaviors. is body of literature has been the subject
of previous systematic reviews [64–67]. One key issue
raised in many of the studies is that the oral health effects
of eating disorders are not unique to eating disordered
behaviors. Most of the associated conditions (e.g., tooth
erosion, susceptibility to caries, changes in salivary flow,
periodontal disease) can be indicative of many other con-
ditions. is finding, paired with the research indicating
OHPs’ lack of confidence in their ability to communicate
about eating disorders, suggests a need for additional
research. Research on interventions to increase OHP
confidence in their ability to raise concerns about disor-
dered eating behaviors will be vital to promoting second-
ary prevention efforts. Additionally, research is needed
on whether increasing OHPs’ communication capacity
impacts patients’ willingness and comfort with disclosure
of eating disordered behaviors with their providers.
is research has a number of limitations. First, articles
were only included if they were available in English. Sev-
eral studies returned in the search were excluded based
on language that may address some of the topics that
were less well represented in this study. Additionally, we
did not evaluate the quality of the research. e quality of
evidence for oral health sequalae of eating disorders has
been previously reviewed. Future research should con-
sider the quality of studies evaluating provider education
and training and patient experiences.
Conclusion
is scoping review sought to assess the state of research
on eating disorders and oral health. While there has been
significant research on the impact of eating disorders
on oral health, there is a need for research in all other
aspects of the intersection between eating disorders and
oral health. In addition, there is a clear need to establish
relationships between oral health professionals and eat-
ing disorder treatment professionals. ese relationships
would improve patients’ referral to specialty care when
symptoms are observed in an oral health setting and
increase the potential for improved oral hygiene and clin-
ical outcomes for individuals with eating disorders.
Abbreviation
OHP Oral health professionals
Acknowledgements
This research was informed by an earlier, unpublished review of the oral health
sequalae of eating disorders conducted by Brittany Davis, Zoe Siegel, and
Morgan Silverman
Author contributions
RP and KP designed the study. MP, SEK and IA conducted the search and
compiled results. RP and IA reviewed articles. RP drafted the initial manuscript.
All authors revised and approved the final manuscript.
Funding
Funding for this research was provided by the Friedman Family Foundation.
The funding organization had no role in the study design; data collection,
analysis, and interpretation; or manuscript writing. Dr. Presskreischer is sup‑
ported by grant T32MH013043 from the National Institute of Mental Health.
Availability of data and materials
Not applicable.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
All authors report no competing interests.
Author details
1 Department of Epidemiology, Columbia University Mailman School of Public
Health, 722 W. 168th Street, New York, NY 10032, USA. 2 Columbia University
College of Dental Medicine, New York, NY, USA. 3 Fordham University, Bronx,
NY, USA. 4 Department of Sociomedical Sciences, Columbia University Mail‑
man School of Public Health, New York, NY, USA. 5 Department of Psychiatry,
Columbia‑WHO Center for Global Mental Health, Columbia University Irving
Medical Center, New York, NY, USA.
Received: 16 January 2023 Accepted: 27 March 2023
References
1. Halmi KA. Psychological comorbidities of eating disorders. In: Agras WS,
Robinson A, editors. The oxford handbook of eating disorders. 2nd ed.
New York: Oxford University Press; 2018. p. 229–43.
2. Mehler PS. Medical complications of anorexia nervosa and bulimia ner‑
vosa. In: Agras WS, Robinson A, editors. The oxford handbook of eating
disorders. 2nd ed. New York: Oxford University Press; 2018. p. 2018.
3. Mitchell JE. Medical comorbidity and medical complications associated
with binge‑eating disorder. Int J Eat Disord. 2016;49(3):319–23.
4. Voderholzer U, Haas V, Correll CU, Korner T. Medical management of eat‑
ing disorders: an update. Curr Opin Psychiatry. 2020;33(6):542–53.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 16 of 17
Presskreischeretal. Journal of Eating Disorders (2023) 11:55
5. Couturier J, Isserlin L, Norris M, Spettigue W, Brouwers M, Kimber M, et al.
Canadian practice guidelines for the treatment of children and adoles‑
cents with eating disorders. J Eat Disord. 2020;8:4.
6. Hay P, Chinn D, Forbes D, Madden S, Newton R, Sugenor L, et al. Royal
Australian and New Zealand college of psychiatrists clinical practice
guidelines for the treatment of eating disorders. Aust N Z J Psychiatry.
2014;48(11):977–1008.
7. Hornberger LL, Lane MA, Committee on A. Identification and man‑
agement of eating disorders in children and adolescents. Pediatrics.
2021;147(1):e2020040279.
8. Klein DA, Sylvester JE, Schvey NA. Eating disorders in primary care: diag‑
nosis and management. Am Fam Phys. 2021;103(1):22–32.
9. National Institute for Health and Care Excellence (N.I.C.E.). Eating disor‑
ders: recognition and treatment. 2020.
10. Academy for Eating Disorders (AED). Eating disorders: a guide to medical
care. 2021.
11. Johnson LB, Boyd LD, Rainchuso L, Rothman A, Mayer B. Eating disorder
professionals’ perceptions of oral health knowledge. Int J Dent Hyg.
2017;15(3):164–71.
12. Flynn M, Austin A, Lang K, Allen K, Bassi R, Brady G, et al. Assessing the
impact of first episode rapid early intervention for eating disorders on
duration of untreated eating disorder: a multi‑centre quasi‑experimental
study. Eur Eat Disord Rev. 2021;29(3):458–71.
13. Austin A, Flynn M, Richards K, Hodsoll J, Duarte TA, Robinson P, et al.
Duration of untreated eating disorder and relationship to outcomes: a
systematic review of the literature. Eur Eat Disord Rev. 2021;29(3):329–45.
14. Mahr F, Farahmand P, Bixler EO, Domen RE, Moser EM, Nadeem T,
et al. A national survey of eating disorder training. Int J Eat Disord.
2015;48(4):443–5.
15. Girz L, Robinson AL, Tessier C. Is the next generation of physicians
adequately prepared to diagnose and treat eating disorders in children
and adolescents? Eat Disord. 2014;22(5):375–85.
16. Ayton A, Ibrahim A. Does UK medical education provide doctors with
sufficient skills and knowledge to manage patients with eating disorders
safely? Postgrad Med J. 2018;94(1113):374–80.
17. Peters MD, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guid‑
ance for conducting systematic scoping reviews. Int J Evid Based Healthc.
2015;13(3):141–6.
18. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al.
PRISMA extension for scoping reviews (PRISMA‑ScR): checklist and expla‑
nation. Ann Intern Med. 2018;169(7):467–73.
19. Burgard M, Canevello A, Mitchell J, De Zwaan M, Crosby R, Wonder‑
lich S, et al. Dental practitioners and eating disorders. Eat Disord.
2003;11(1):9–13.
20. DeBate RD, Bleck JR, Raven J, Severson H. Using intervention mapping to
develop an oral health e‑curriculum for secondary prevention of eating
disorders. J Dent Educ. 2017;81(6):716–25.
21. DeBate RD, Cragun D, Gallentine AA, Severson HH, Shaw T, Cantwell
C, et al. Evaluate, assess, treat: development and evaluation of the EAT
framework to increase effective communication regarding sensitive oral‑
systemic health issues. Eur J Dent Educ. 2012;16(4):232–8.
22. DeBate RD, Plichta SB, Tedesco LA, Kerschbaum WE. Integration of oral
health care and mental health services: dental hygienists’ readiness and
capacity for secondary prevention of eating disorders. J Behav Health
Serv Res. 2006;33(1):113–25.
23. Debate RD, Severson H, Zwald ML, Shaw T, Christiansen S, Koerber A, et al.
Development and evaluation of a web‑based training program for oral
health care providers on secondary prevention of eating disorders. J Dent
Educ. 2009;73(6):718–29.
24. DeBate RD, Severson HH, Cragun D, Bleck J, Gau J, Merrell L, et al.
Randomized trial of two e‑learning programs for oral health students on
secondary prevention of eating disorders. J Dent Educ. 2014;78(1):5–15.
25. DeBate RD, Shuman D, Tedesco LA. Eating disorders in the oral health
curriculum. J Dent Educ. 2007;71(5):655–63.
26. Debate RD, Tedesco LA. Increasing dentists’ capacity for secondary
prevention of eating disorders: identification of training, network, and
professional contingencies. J Dent Educ. 2006;70(10):1066–75.
27. DeBate RD, Tedesco LA, Kerschbaum WE. Knowledge of oral and physical
manifestations of anorexia and bulimia nervosa among dentists and
dental hygienists. J Dent Educ. 2005;69(3):346–54.
28. Debate RD, Vogel E, Tedesco LA, Neff JA. Sex differences among dentists
regarding eating disorders and secondary prevention practices. J Am
Dent Assoc. 2006;137(6):773–81.
29. DiGioacchino RF, Keenan MF, Sargent R. Assessment of dental practition‑
ers in the secondary and tertiary prevention of eating disorders. Eat
Behav. 2000;1(1):79–91.
30. Frimenko KM, Murdoch‑Kinch CA, Inglehart MR. Educating dental
students about eating disorders: perceptions and practice of interprofes‑
sional care. J Dent Educ. 2017;81(11):1327–37.
31. Galindo DF, Butura CC. Immediate loading of dental implants in the
esthetic region using computer‑guided implant treatment software and
stereolithographic models for a patient with eating disorders. J Prostho‑
dont. 2014;23(2):98–103.
32. Giraudeau N, Camman P, Pourreyron L, Inquimbert C, Lefebvre P. The
contribution of teledentistry in detecting tooth erosion in patients with
eating disorders. Digit Health. 2021;7:20552076211019250.
33. Johansson AK, Johansson A, Nohlert E, Norring C, Astrom AN, Tegelberg
A. Eating disorders: knowledge, attitudes, management and clinical
experience of Norwegian dentists. BMC Oral Health. 2015;15(1):124.
34. Lee JY, Kim SW, Kim JM, Shin IS, Yoon JS. Two cases of eating disorders
in adolescents with dental braces fitted prior to the onset of anorexia
nervosa. Psychiatry Investig. 2015;12(3):411–4.
35. Turhani D, Ohlmeier KH, Sutter W, Kielbassa AM. Undesirable course of
an oral implant rehabilitation in a patient with a long history of bulimia
nervosa: case report and review of the literature. Quintessence Int.
2019;50(1):68–79.
36. Back‑Brito GN, da Mota AJ, de Souza Bernardes LA, Takamune SS, Prado
Ede F, Cordas TA, et al. Effects of eating disorders on oral fungal diversity.
Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;113(4):512–7.
37. Boillot A, Ringuenet D, Kapila Y, Pallier A, Colon P, Bouchard P, et al. High
serum ferritin levels are associated with a reduced periodontium in
women with anorexia nervosa. Eat Weight Disord. 2020;25(6):1763–70.
38. de Moor RJ. Eating disorder‑induced dental complications: a case report.
J Oral Rehabil. 2004;31(7):725–32.
39. Dynesen AW, Bardow A, Petersson B, Nielsen LR, Nauntofte B. Salivary
changes and dental erosion in bulimia nervosa. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 2008;106(5):696–707.
40. Emodi‑Perlman A, Yoffe T, Rosenberg N, Eli I, Alter Z, Winocur E. Preva‑
lence of psychologic, dental, and temporomandibular signs and symp‑
toms among chronic eating disorders patients: a comparative control
study. J Orofac Pain. 2008;22(3):201–8.
41. Hermont AP, Pordeus IA, Paiva SM, Abreu MH, Auad SM. Eating disorder
risk behavior and dental implications among adolescents. Int J Eat Disord.
2013;46(7):677–83.
42. Imai T, Michizawa M. Necrotizing sialometaplasia in a patient with an
eating disorder: palatal ulcer accompanied by dental erosion due to
binge‑purging. J Oral Maxillofac Surg. 2013;71(5):879–85.
43. Johansson AK, Norring C, Unell L, Johansson A. Eating disorders and oral
health: a matched case‑control study. Eur J Oral Sci. 2012;120(1):61–8.
44. Lifante‑Oliva C, Lopez‑Jornet P, Camacho‑Alonso F, Esteve‑Salinas J.
Study of oral changes in patients with eating disorders. Int J Dent Hyg.
2008;6(2):119–22.
45. Lourenco M, Azevedo A, Brandao I, Gomes PS. Orofacial manifestations in
outpatients with anorexia nervosa and bulimia nervosa focusing on the
vomiting behavior. Clin Oral Investig. 2018;22(5):1915–22.
46. Lundgren JD, Williams KB, Heitmann BL. Nocturnal eating predicts tooth
loss among adults: results from the Danish MONICA study. Eat Behav.
2010;11(3):170–4.
47. Otsu M, Hamura A, Ishikawa Y, Karibe H, Ichijyo T, Yoshinaga Y. Factors
affecting the dental erosion severity of patients with eating disorders.
Biopsychosoc Med. 2014;8:25.
48. Pallier A, Karimova A, Boillot A, Colon P, Ringuenet D, Bouchard P, et al.
Dental and periodontal health in adults with eating disorders: a case‑
control study. J Dent. 2019;84:55–9.
49. Paszynska E, Hernik A, Slopien A, Roszak M, Jowik K, Dmitrzak‑Weglarz
M, et al. Risk of dental caries and erosive tooth wear in 117 children and
adolescents’ anorexia nervosa population‑a case‑control study. Front
Psychiatry. 2022;13:874263.
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50. Paszynska E, Schlueter N, Slopien A, Dmitrzak‑Weglarz M, Dyszkiewicz‑
Konwinska M, Hannig C. Salivary enzyme activity in anorexic persons‑a
controlled clinical trial. Clin Oral Investig. 2015;19(8):1981–9.
51. Range H, Pallier A, Ali A, Huas C, Colon P, Godart N. Risk factors for oral
health in anorexia nervosa: comparison of a self‑report questionnaire and
a face‑to‑face interview. Int J Environ Res Public Health. 2021;18(8):4212.
52. Sales‑Peres SHC, Araujo JJ, Marsicano JA, Santos JE, Bastos JRM.
Prevalence, severity and etiology of dental wear in patients with eating
disorders. Eur J Dent. 2014;8(1):68–73.
53. Shaughnessy BF, Feldman HA, Cleveland R, Sonis A, Brown JN, Gordon
CM. Oral health and bone density in adolescents and young women with
anorexia nervosa. J Clin Pediatr Dent. 2008;33(2):87–92.
54. Ximenes R, Couto G, Sougey E. Eating disorders in adolescents and their
repercussions in oral health. Int J Eat Disord. 2010;43(1):59–64.
55. Strużycka I, Lussi A, Boguslawska‑Kapala A, Rusyan E. Prevalence of
erosive lesions with respect to risk factors in a young adult population in
Poland‑across‑sectional study. Clin Oral Investig. 2017;21(7):2197‑203.
56. Conviser JH, Fisher SD, Mitchell KB. Oral care behavior after purg‑
ing in a sample of women with bulimia nervosa. J Am Dent Assoc.
2014;145(4):352–4.
57. Dynesen AW, Gehrt CA, Klinker SE, Christensen LB. Eating disorders:
experiences of and attitudes toward oral health and oral health behavior.
Eur J Oral Sci. 2018;126(6):500–6.
58. Johansson AK, Mjanger Ovretvedt T, Reinholtsen KK, Johansson A. Eating
disorders: an analysis of self‑induced vomiting, binge eating, and oral
hygiene behavior. Int J Clin Pract. 2022;2022:6210372.
59. Johansson AK, Norring C, Unell L, Johansson A. Diet and behavioral habits
related to oral health in eating disorder patients: a matched case‑control
study. J Eat Disord. 2020;8:7.
60. Sharifian MJ, Pohjola V, Kunttu K, Virtanen JI. Association between dental
fear and eating disorders and body mass index among finnish university
students: a national survey. BMC Oral Health. 2021;21(1):93.
61. Sirin Y, Yucel B, Firat D, Husseinova‑Sen S. Assessment of dental fear and
anxiety levels in eating disorder patients undergoing minor oral surgery. J
Oral Maxillofac Surg. 2011;69(8):2078–85.
62. Willumsen T, Graugaard PK. Dental fear, regularity of dental attendance
and subjective evaluation of dental erosion in women with eating disor‑
ders. Eur J Oral Sci. 2005;113(4):297–302.
63. Anderson K, Accurso EC, Kinasz KR, Le Grange D. Residents’ and fellows’
knowledge and attitudes about eating disorders at an academic medical
center. Acad Psychiatry. 2017;41(3):381–4.
64. Frydrych AM, Davies GR, McDermott BM. Eating disorders and oral health:
a review of the literature. Aust Dent J. 2005;50(1):6–15.
65. Lo Russo L, Campisi G, Di Fede O, Di Liberto C, Panzarella V, Lo ML.
Oral manifestations of eating disorders: a critical review. Oral Dis.
2008;14(6):479–84.
66. Kisely S, Baghaie H, Lalloo R, Johnson NW. Association between poor oral
health and eating disorders: systematic review and meta‑analysis. Br J
Psychiatry. 2015;207(4):299–305.
67. Monda M, Costacurta M, Maffei L, Docimo R. Oral manifestations of
eating disorders in adolescent patients. A review Eur J Paediatr Dent.
2021;22(2):155–8.
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