Increasing dental professional awareness of disordered eating behaviours and oral health impacts in people living with severe obesity

Abstract

Background

People living with severe obesity are at an elevated risk of poor oral health. Contributing factors to poor oral health in this population group include cariogenic dietary behaviours and social determinants of health. There has been minimal discussion of the possible impacts of disordered eating behaviours on oral health particularly for those living with obesity.

Aim

This short communication aims to increase the awareness among dental teams of disordered eating behaviours and possible impacts on oral health particularly for patients living with obesity.

Methods

A short evidence-based report was developed to highlight the relevance and importance of increasing dental professional awareness of disordered eating behaviours.

Results

Data on prevalence of disordered eating behaviours in the general population and individuals living with severe obesity have been reported. Some studies have revealed there may be a higher prevalence of some forms of disordered eating behaviours among people living with obesity. Potential negative sequelae on oral health include increased risk of missing teeth, periodontal disease, and active dental caries.

Conclusions

Collaboration between the disciplines of oral health and nutrition and dietetics, and with primary care providers such as general practitioners, is important to foster successful nutritional strategies for both general and oral health in patients living with obesity. Suggested approaches include joint professional society statements and increased training for the dental profession on oral health impacts of disordered eating behaviours to facilitate early identification, provision of tailored oral health care and signposting for support. The integration of the dental team into current obesity management will add to their supportive role in the overall management of people living with severe obesity.

People living with severe obesity are at an elevated risk of poor oral health (Malik et al., 2024b). Contributing factors to poor oral health in this population group include cariogenic dietary behaviours, such as daily consumption of sugar sweetened food and drinks (Malik et al., 2024a), lower use of dental services (Malik et al., 2023b) and also social determinants of health, including lower health literacy, housing stability, food security, education, and income (Javed et al., 2022). The associations between oral disease and health issues within this cohort reflect established links between obesity, co-morbidities and aspects of oral health such as periodontal disease (Malik et al., 2024b). Obesity is a risk factor for a number of systemic conditions that increase dental disease risk, including type 2 diabetes mellitus, cardiovascular disease, obstructive sleep apnoea and micronutrient inadequacy due to poor diet quality (Cullinan, 2012; Wijey et al., 2019). Poor diet quality in people living with severe obesity may be secondary to disordered eating, low-nutrition food choices, the effects of obesity modifying medications or bariatric surgery (Ciobârcă et al., 2022). In general, the effect of diet on oral health has predominantly focused on the localised effects on dental hard tissues, with dental caries and dental erosion common sequelae (König, 2000). However, dental teams are typically unaware of disordered eating behaviours and their sequelae, and that these can present in people living with severe obesity, which is the focus of this short communication.

Eating disorders vs disordered eating behaviours?

While there is overlap, it is important for the dental team to appreciate the differences between eating disorders and disordered eating behaviours. Dental teams may be more familiar with eating disorders. Eating disorders are complex psychiatric conditions associated with significant psychological and physical impairment and are often chronic in nature, particularly if not addressed in a timely manner (Jenkins et al., 2011). Sequelae of eating disorders include a greater risk of suicide attempts, mortality, and poorer quality of life relative to the general population (Barakat et al., 2023). Disordered eating behaviours covers a spectrum, from highly restricted eating patterns associated with anorexia nervosa, to altered patterns of food consumption or purging behaviours, as seen in bulimia nervosa, night eating syndrome (NES) or binge eating disorder (BED) (McCuen-Wurst et al., 2018). For the first time, NES and BED were included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) 5^th edition as formal diagnoses. NES is defined as the circadian delay in food intake, evidenced by evening hyperphagia (at least 25% of daily food intake ingested after the evening meal) and/or nocturnal awakenings with food ingestion at least two times per week (American Psychiatric Association, 2013). The DSM-V defines BED as recurrent episodes of binge eating (eating unusually large amounts of food while experiencing a feeling of loss of control) with marked distress, the absence of extreme weight compensatory behaviours and graded for severity from mild to extreme (American Psychiatric Association, 2013; Grilo et al., 2015). Specific additional criteria must be met for diagnosis of NES or BED.

Risk factors for disordered eating behaviours include depression related symptoms and body dissatisfaction, genetic and environmental factors (Baker et al., 2009; Goldschmidt et al., 2015). While disordered eating behaviours may affect individuals at any body weight, NES and BED have previously been reported as more prevalent in people living with obesity (Lundgren et al., 2010), contributing to weight gain over time and higher risk of diabetes and other metabolic conditions (McCuen-Wurst et al., 2018).

Prevalence of night eating syndrome and binge eating disorder

Prevalence of NES in the general population has been reported as 1-2% (Lavery and Frum-Vassallo, 2022). The prevalence of BED is currently estimated to affect 1.5% of women and 0.3% of men worldwide, with a higher prevalence in adolescence which is often transient (Keski-Rahkonen, 2021). However, the prevalence of dietary patterns posing risk to oral health among those living with severe obesity has been minimally quantified in the literature. Self-reported nocturnal eating and binge eating behaviours, as potential markers of NES and BED, affected 14.8% and 58.0% respectively, of a cohort of 81 participants with clinically severe obesity attending a specialised obesity service in Australia (Malik et al., 2024a). Other self-reported dietary risk behaviours in this group included purging (4.9%), regurgitation of food (14.8%) and taking medications with sugary food or drink (21.0%) (Malik et al., 2024a).

Possible impacts of disordered eating behaviours on oral health

Apart from negative impacts on nutrition and weight, disordered eating behaviours increase the risk of dental diseases, such as dental caries and/or dental erosion secondary to intrinsic or extrinsic acid attack, with an associated negative impact on oral health-related quality of life. This is likely to be associated with compromised frequency (for example, grazing patterns or minimal time between meals), consistency (for example, foods which take longer to clear from the mouth such as stickier or viscous textured foods), and timing of dietary intake where a reduced salivary flow at night predisposes individuals to increased dental disease risk (Lundgren et al., 2010). Anecdotally individuals variably engage in oral hygiene behaviours following nocturnal food intake which may further increase their risk, particularly if oral hygiene practices are suboptimal (Lundgren et al., 2010). A cross sectional study of 174 individuals from a US-based academic faculty dental practice found that NES was a significant predictor of missing teeth, periodontal disease and active dental caries (Lundgren et al., 2010). Untreated dental disease may lead to an individual experiencing pain, bleeding, swelling, dentine hypersensitivity, dry mouth, difficulty with chewing, smiling, speech and loss of functional capacity. It is therefore imperative that dental teams are aware of disordered eating behaviours in order for signs and oral manifestations to be recognised early and tailored oral health advice provided and/or referral for nutritional advice.

An individual living with obesity may present with multiple comorbidities with potential negative impacts on their oral health for example in relation to the presence of periodontal disease, tooth surface loss and possibly dental caries (Lundgren et al., 2010). Patients referred for bariatric surgery have been found to have a higher prevalence of risk factors for dental erosion and dental caries (de Almeida Bastos et al., 2018). A recently published study reported increased risk of caries among patients with higher body mass index beyond 40 kg/m² (Taghat et al., 2022) although there is mixed evidence between adult obesity and dental caries across the literature. There is strong evidence that improvement of oral health for example through periodontal treatment can improve glycaemic control (Herrera et al., 2023). This further reinforces the benefits of the early recognition of untreated dental disease by the dental team which could result in improved general health outcomes and timely management.

Given the evidence around reduced dental service utilisation by people living with severe obesity (Malik et al., 2023b), it is important to consider that pain or infection caused by untreated dental disease could also influence dietary intake by interfering with chewing function. This may result in avoidance of particular foods, such as vegetables, with increased cooking times to achieve a softer texture, albeit greater loss of nutrients, or preference for high-sugar containing foods, leading to further weight gain (Basher et al., 2017; Sheiham, 2005). Furthermore, these symptoms may contribute to lower oral health-related quality of life for those living with severe obesity, although the current evidence for this is mixed (Malik et al., 2024b). These recent findings highlight the important supportive role that the dental team can have in the management of people living with severe obesity.

How can dental teams support people with disordered eating behaviours and obesity?

Dental professionals have the unique opportunity to provide support and information to people living with severe obesity who are presenting for oral care and who report disordered eating behaviours. Screening and treatment for disordered eating behaviours should be available to all individuals living with severe obesity. There may be particular subgroups for whom this is particularly advantageous such as those in extreme circumstances, e.g. when medical complications or low socioeconomic status are present and/or in the setting of bariatric surgery. This should be reinforced within both dentistry and oral health therapy tertiary education.

There has been emphasis on the need for evidence-based and tailored dietary counselling for people at high risk for dental disease (König, 2000). However, people living with severe obesity have not typically been considered in this high-risk category by dental professionals. Training of the dental workforce regarding assessment and management of disordered eating behaviours that contribute to poor oral health in people living with severe obesity is therefore needed.

The current provision of evidence-based nutrition information encourages reduced consumption of ultra-processed and high energy diets, which are high in fat, sugar and carbohydrates (Levine, 2012; Östberg et al., 2012). Dental professionals already engage in preventive advice to reduce cariogenic and erosive dietary risk factors. However, tailored preventive dental advice can be provided to reflect the nature and type of disordered eating behaviour related to severe obesity, if it is identified. This would need to be incorporated into oral health education of dental professionals for it to be part of routine practice. For example, practical suggestions for night or binge eating habits include recommending high-concentration fluoride toothpaste, incorporating products containing casein phosphopeptide-amorphous calcium phosphate (Suresh et al., 2024) and fluoridated water rinses following any binge or night eating with a gap of at least 30 minutes before toothbrushing if there is an associated acid attack (Ganss et al., 2012).

What needs to change to improve dental team input?

A collaboration between the disciplines of oral health and nutrition and dietetics is important to foster successful nutritional strategies for both general and oral health in patients living with obesity (Söderling, 2001). Involvement from primary healthcare providers such as general practitioners should also be encouraged. This would allow for pathways to be developed to support patients with both obesity and disordered eating behaviours and provide clear direction on when to seek specialist input. Joint society statements, with simple, realistic and positive language, are likely to have an important role (Söderling, 2001). There is a need for improved education and awareness among dental professionals regarding the behavioural aspects of eating in patients living with obesity. Training and continuing professional development courses for the entire dental team and embedding knowledge and skills regarding disordered eating behaviours into undergraduate dental programs are recommended future approaches. Specifically, this may involve the incorporation of screening tools for eating behaviours into dental assessments. Continuing education opportunities on the oral-systemic links related to obesity is also required.

The literature proposes that a key future role of the dental professional in primary care settings is in the screening of patients and initiation of referral to a dietitian, medical obesity service, behavioural specialist or general practitioner when patients present with disordered eating behaviours. Referral pathways should be clearly outlined and developed. This goal for dental teams to play a screening role and collaborate with multidisciplinary healthcare teams can help reduce malnutrition and oral, chronic and systemic disease risks through early detection (Hague and Touger-Decker, 2008). Conversely, these practitioners can also encourage individuals at risk of dental disease to attend for regular preventive dental visits, in conjunction with other multidisciplinary supports available to them. While there is no documented evidence this is routine current practice in any international context, a recent population-based United Kingdom based study found that the public is largely receptive to receiving weight screening and the offer of weight interventions from dental teams (Large et al., 2024a). In fact, an ideal model is likely to be the inclusion of dental professionals into multidisciplinary clinical care teams for people seeking treatment for obesity and metabolic management (Malik et al., 2024c), thereby integrating oral health into general health messaging, leading to improved overall health outcomes (Sheiham, 2005). This is most beneficial for the patient living with severe obesity, who is likely to have complex barriers to attending multiple appointments at different sites (Al-Khudairy et al., 2017).

Processes should be developed to build the confidence and expertise of dental professionals in discussing obesity and associated complications with their patients (Large et al., 2024b). A non-stigmatising approach is required to discuss these issues with the patient living with severe obesity, while fostering confidence in a group often suffering from low self-esteem and complex medical and psychosocial concerns (Malik et al., 2023a; Vaidya, 2006).

The relationship between obesity, disordered eating behaviours and dental disease is important and under recognised by many. The dental team has an important, to date underdeveloped, role in the identification of disordered eating behaviours. The dental team, with training, could play an important role in the management of people with disordered eating behaviours in terms of recognition of oral signs and symptoms of the condition(s) and signposting or referral to supportive services as required. Further, dental professionals should be embedded within multidisciplinary clinical care teams who treat people living with severe obesity who may also present with disordered eating behaviours.