With the onset of COVID-19 and a political environment where governments weigh imposing restrictions regarding where consumers can gather outside of their homes, a rise in mental health issues has inadvertently also occurred. The Centers for Disease Control and Prevention (CDC) states on its website that “fear and anxiety about a new disease and what could happen can be overwhelming and cause strong emotions in adults and children.” 1
The CDC further explains that “public health actions, such as social distancing, can make people feel isolated and lonely and can increase stress and anxiety.”1 The majority of people acknowledge that these public health and safety measures are necessary to reduce the spread of the virus. However, this recommendation does not reduce the impact this new world has on many people who struggle with mental health issues.
These can be issues that existed prior to the pandemic and are being exacerbated by the isolation and imposed limitations. Or, they can be new and developing issues as a result of it.
Eating Disorders During a Pandemic
Regardless of the “why,” dental hygienists need to have a solid understanding of how to provide thorough and holistic care. Specifically, we will look at the issue of eating disorders and signs that can be found by the dental hygienist during oral exams, as well as other physical indications that suggest a patient might be dealing with this disorder. We also will look at the next steps that dental hygienists can take to help these individuals while understanding that the COVID-19 pandemic has put a significant strain on the healthcare system, where it can be more difficult for an individual to receive inpatient treatment.
Looking at all of these factors, it can be understood that, due to the rising numbers of individuals who suffer from mental illnesses including eating disorders during the COVID-19 pandemic, there is a growing need for dental hygienists to be familiar with the signs of the disease and to be knowledgeable about the dental treatments and comprehensive resources available to help these individuals.
Eating Influences During Pandemic
According to the Statistics Canada website, eating disorders are a result of extremely disturbing eating habits. It explains that anorexia nervosa is related to a refusal to preserve healthy body weight. In contrast, bulimia nervosa is classified as taking in excessive amounts of food and then feeling a need to rid the body of it.
The website further explains that both anorexia nervosa and bulimia nervosa are “similar in terms of their disturbed perception in body shape and weight … and in their fear of gaining weight. However, individuals with anorexia nervosa often feel in control of their eating and body weight, whereas individuals with bulimia nervosa feel out of control.”2
It goes on to explain what should be considered a very important factor in the development of eating disorders during the COVID-19 pandemic: “Society’s views and the media tend to portray the message that thinness is attractive, which may contribute to a distorted body image.”2 Many young adults are spending a majority of their pandemic-era days indoors, likely spending much more of their time on social media and watching television. They are being subjected to a much higher amount of this than prior to the pandemic.
In an article titled, “COVID-19 and Implications for Eating Disorders,” the authors confirm this concern by stating, “Further risk factors may also contribute to the likelihood of developing an eating disorder, such as increased time spent using social media and the toxic influence of the objectification of the thin ideal. Isolation and loneliness are common consequences of anorexia nervosa and may be exaggerated by imposed quarantine.”3
The study further reports that, while there is not yet significant research on eating disorders related to the pandemic, we must consider that these patients are at a higher risk of emotional, psychological, and physical stress related to confinement, as well as distress directly caused by uncertainty and decreases in treatment typically available.
The Dental Hygienist’s Role
It is up to each dental hygienist to be aware of this growing prevalence of eating disorders and be aware of the signs and possible help they can offer to the patient suffering from the disease. We need to consider what the dental hygienist can do to help.
Looking specifically at the oral manifestations of eating disorders, we can refer to an article titled, “Oral Manifestations of Eating Disorders: A Critical Review” by Lo Russo, et al. The review article states that “oral manifestations occurring in eating disorders are mainly caused by nutritional deficiencies and consequent metabolic impairment but may also be related to lack of importance given to personal hygiene/care, underlying psychological disturbances, modified nutritional habits … or assumption of certain drugs.”4
The article classifies six possible manifestations of eating disorders that dental hygienists should be aware of.
1) Mucosal lesions. First, there are mucosal lesions. Because of poor nutritional habits among individuals with eating disorders, there is an increase in deficiency of nutrients such as iron and vitamins (specifically of the B group). These deficiencies lead to complications such as generalized mucosal atrophy, which is often noted on the tongue.
This mucosal atrophy will also likely cause a strong burning sensation that can be more intense on the tongue but generally can be diffuse in nature. We can also expect erythematous mucosal lesions on the soft palate either from the acid wear from the act of vomiting or due to the trauma of repeatedly using an object to induce vomiting.
2) Gingival inflammation. Next, we look at the periodontal manifestations, where we consider that those affected by eating disorders could have poor hygiene habits, putting them at a higher risk for gingival inflammation and, consequently, periodontal disease.
3) Other periodontal issues. Looking again at nutritional deficiencies, eating disorder patients can also have vitamin C deficiency (scurvy), resulting in collagen synthesis issues. This leads to problems such as gingival swelling, tooth mobility, or other periodontal issues.
4) Dental erosion. Moving on to dental manifestations, dental erosion will be a significant warning sign noted mainly on the palatal side of the maxillary and mandibular teeth, both anteriorly and posteriorly. While this is often caused by the actual act of vomiting and acid erosion, it can often be caused by overuse of sports drinks (from the abundance of physical activity the individual participates in) or energy drinks (to boost energy levels). If a patient presents with erosion, providing nutritional counseling, and discussing the levels of sugars in these drinks, including the oral implications, is recommended.
5) Caries. They will also have a high caries risk due to the frequency of sugary intake from gum or candies, for example, that are consumed to alleviate the feeling of hunger.
6) Parotid gland swelling. In terms of salivary manifestations, a very common sign (and often one of the earlier manifestations in general) is the swelling of the parotid glands. This is directly caused by peripheral autonomic neuropathy resulting from the eating disorder.
Other manifestations can include dysgeusia (problems with the taste sensation), xerostomia, immune system dysfunctions resulting from nutritional deficiencies, or osteoporosis.
Referring back to the “COVID-19 and the Implications for Eating Disorders” article, the authors reviewed a pilot study in the eating disorder unit at the Bellvitge University Hospital in Barcelona, Spain. A group of 32 individuals, all with various categories of eating disorders, participated in a telephone survey that assessed the implications of the first two weeks of confinement.
The study found that “almost 38% … reported impairments in their eating disorder symptomatology and 56.2% reported additional anxiety symptoms, of whom, four patients noted that stress made it difficult for them to control their grazing behaviour and emotional eating.” 3
The article adds that, while many countries have put significant time and resources into developing methods of care alternative to in-person counseling, “in the context of COVID-19 … only urgent visits and inpatient treatment settings for severe eating disorder cases are provided and – where possible – online treatments (instead of face-to-face) have been recommended. Restrictions include the closure of day hospitals and outpatient facilities.”3
Some dental patients with eating disorders are potentially viewed as being non-severe cases, and unable to access the treatment they need, avoiding a progression to an unsafe level. This is where dental hygienists can recognize that early signs and symptoms are possibly going to be overlooked by other treatment personnel. Our ability to diagnose earlier signs becomes infinitely more important.
Aiding the Eating Disorder Patient
With the understanding of the severity of eating disorders and the oral manifestations of them, the question becomes, “What can the dental hygienist do to help the patient?”
Dental hygienists work in busy dental offices office, often stressed and feeling rushed through the workday. They feel the pressure to “catch up” if behind schedule. With every single patient seen, though, there is a need for dental hygienists to be attentive, professional, and thorough. If we are too prioritized in getting through the appointment and thinking in terms of the schedule, signs, and medical history, pieces of information will inevitably be missed or overlooked.
Additionally, when a practitioner is too rushed, they can appear to be uncaring or even inattentive. These do not equal scenarios where a person suffering from a mental illness of any kind will feel safe to discuss something so personal to them.
When it comes to approaching the subject of actual signs noted by the dental hygienist, it is vital to use good communication skills. Giving the patient their full attention and not appearing to come across as judgemental in any way is vital.
When it comes to situations where we are treating patients with eating disorders, an advisory from the College of Dental Hygienists of Ontario (CDHO) states that, according to Ontario legislation, the dental hygienist must record a thorough medical history, advice from the physician/primary care provider relative to the patient’s condition, the decision made by the dental hygienist (with reasons), compliance with the precautions required, all procedures used, and any advice given to the patient.
Each individual dental hygienist should familiarize themselves with the protocols of their own regulatory body.
The CDHO also advises that the patient should alert their healthcare provider of any changes in the mouth indicative of suspicious lesions and stress the importance of regular oral health examinations and preventative oral care.5
Each dental hygienist is recommended to do their own research into the resources available in their communities. Canadian organizations helping patients or families/caregivers of those affected are the National Eating Disorder Information Centre (NEDIC), Canadian Mental Health Association (CMHA), and the National Eating Disorders Association (NEDA). Alternatively, in the United States, individuals can reach out to Mental Health America (MHA), the National Institute of Health (NIH), or the National Institute of Mental Health (NIMH).
The pandemic is far from over. The reality is that social isolation will be in people’s future for a while longer. It is important to understand that teens and other at-risk individuals will be in their homes. As noted earlier, this will most likely lead to a much longer time spent on variations of social media.
The dental profession understands how eating disorders and mental health are linked. It is a very good idea to discuss this trend with patients. A gentle reminder could go along way with those who are going through a difficult time and adding to the problem with the amount of time spent on phones, watching TV, etc. They need recommendations and support as they consider healthier ways to fill the time.
Now Listen to the Today’s RDH Dental Hygiene Podcast Below:
- COVID-19 (Coronavirus): Coping with Stress. (2020, December 11). Centers for Disease Control and Prevention. Retrieved from www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/managing-stress-anxiety.html,
- Section D: Eating Disorders. (2015, November 27). Statistics Canada. Retrieved from www.150.statcan.gc.ca/n1/pub/82-619-m/2012004/sections/sectiond-eng.htm.
- Fernandez-Aranda, F., Casas, M., Claes, L., et al. Covid-19 and Implications for Eating Disorders. European Eating Disorders Review. 2020; 28(3): 239-45. Retrieved from https://pubmed.ncbi.nlm.nih.gov/32346977/.
- Lo Russo, L., Campisi, G., Di Liberto, C., et al. Oral Manifestations of Eating Disorders: A Critical Review. Oral Diseases. 2008; 14(6): 479-84. Retrieved from https://pubmed.ncbi.nlm.nih.gov/18826377/.
- CDHO Advisory Eating Disorders. (2019, September 18). College of Dental Hygienists of Ontario. Retrieved from https://www.cdho.org/Advisories/CDHO_Advisory_Eating_Disorders.pdf.