Impact of an oral health education intervention among a group of patients with eating disorders (anorexia nervosa and bulimia nervosa)

Background It is recognized that eating disorders are serious psychosocial illnesses that affect many adolescents and adults. A pre and post survey study was developed to assess demographics, oral health knowledge and self-image of patients with eating disorders participating in a hospital-based eating disorder clinic using an original oral health education program. The program’s aim is to change the self-image and oral health practices of patients with anorexia-binge eating/purging (AN-BP) and bulimia nervosa (BN) disorders. Methods A pre-survey was completed by each study participant prior to attending the three educational sessions over a six-week period. A post survey questionnaire was completed after participation in all the educational presentations. Forty-six patients attended all three educational sessions and completed the pre and post-questionnaires. Results Most patients knew in advance that AN-BP and BN behavior can cause erosion of the teeth but only 30% knew the most likely location for the erosion to occur. But, following completion of the educational interventions, 73% answered the location correctly. Patients who reported going to the dentist regularly were significantly more likely to respond that their teeth/mouth had a positive effect on how they looked to themselves and to others, their general health, and their general happiness. Positive responses to the effect of the teeth/mouth on kissing and romantic relationships were also significantly higher for those who go to the dentist regularly compared to those who do not. Conclusions There is a need to further understand AN-BP and BP patients’ oral health knowledge and self-image perceptions as it relates to their smile (teeth, mouth) to assist in developing a standardized oral health program for eating disorder centers to implement into their daily curricula. A dental team member in an interdisciplinary eating disorder treatment team is important. Including an oral health education program improves patients’ oral hygiene and oral health knowledge, as well as provides a supportive environment to empower the patients to take control of their overall oral health. Trial registration This study was retrospectively registered on April 18, 2019 in ClinicalTrials.gov, Identifier: NCT03921632.


Plain English summary
Using a pre and post survey, this study examined the demographics, oral health knowledge and self-image among a group of patients diagnosed with AN-BP or BN. The study participants completed a survey instrument before attending three educational presentations. A post survey questionnaire was completed after the final educational presentation. After participating in the educational presentations, 95% knew that tooth erosion was the most common oral effect of eating disorders (pre education = 78%) and 73% knew where the erosion most commonly occurred (pre education = 30%). Patients who went to a dentist regularly were significantly more likely to report that their teeth/mouth had a positive effect on how they looked to themselves and others, romantic relationships, general health, and their level of happiness. Providing an oral health education program improves the patients' oral health knowledge and empowers them to be proactive in caring for their teeth.

Introduction
Eating disorders are psycho-social illnesses that affect many adolescents and adults [1]. Individuals with eating disorders can also have additional health issues [2]. Some of these include diabetes, loss of menses in females, heart failure, very low self-esteem, metabolic, cardiovascular and endocrine disturbances [2], and distorted perception of body image [3]. In addition to these systemic problems, oral/dental trauma and dental caries, increase in xerostomia and parotid salivary gland swelling, dental erosion, and periodontal disease have been cited in the literature and are most associated with anorexia-binge eating/purging (AN-BP and bulimia nervosa (BN) [4]. Roberts and Li stated that the very negative self-perception and self-esteem that many individuals with anorexia nervosa and bulimia nervosa reported could be, in part, a cause for their lack of oral hygiene and increase in dental disease [3].
Often there are general health education programs in eating disorder clinics. However, we are unaware of any established oral health education programs to change and improve patients' oral health behaviors and self-perception as it relates to their smile [5,6]. According to the Academy of Eating Disorders, the American Psychological Association, and the American Dental Association, proper oral health care for patients with eating disorders is fragmented. Johnson et al. reported "In addition to patient's lack of knowledge, there is very little evidence, if any, documenting the collaborative interaction between oral health and eating disorder professionals. Individuals who receive treatment for an eating disorder are typically not viewed as needing specialized, preventive oral care and commonly fail to receive appropriate oral health care, or recommendations from the eating disorder treatment team" [7]. There is no indication that these patients have access to the proper oral health education and information. Without adequate oral health education for patients with eating disorders, oral disease can become severe and impact the patient's ability to eat, speak, and socialize [7].
The extent of oral/dental education in curricula within eating disorder treatment centers is unexplored to date [5,6,8]. Evidence of patients' self-image as it relates to their smile is also unexplored. The limited studies evaluating perception of oral health knowledge in eating disorder treatment programs suggest the need to further explore provider and client/patient barriers and perception towards oral care [7]. Integrating an oral health program focusing on improving self-image through dental education is essential in providing patients an interdisciplinary approach to care for the entire person. Understanding eating disorder patients' oral health knowledge and perceptions of self-image as it relates to their smile will assist in developing a standardized oral health program for eating disorder treatment centers to implement into their daily curricula.

Methods
The authors designed a pre and post survey study to assess demographics, oral health knowledge, and selfimage of patients diagnosed with AN-BP and BN participating in a hospital-based eating disorder clinic. The authors consulted and collaborated with eating disorder specialists, dentists, dental hygienists, and psychiatrists in designing the surveys and the education program. An original oral health education program, called Smiles Matter, was created consisting of three different presentations/discussions. Each Smiles Matter session consisted of 15-20 min of didactic learning, 10 min of a group/personal exercise, and 10 min of questions that the patients had about their oral health or the topic of the day (Fig. 1).
Patients were consented prior to participating in the study and educational program. A pre-survey was completed by each participant prior to attending the three educational sessions. The presentations were given weekly and addressed general oral health education, esthetics, effects of eating disorders and oral pain, and nutrition for oral health. A post survey questionnaire was completed after the patient had participated in all three educational presentations. A respondent could choose not to answer all questions and some did so. Therefore, the denominator for some questions is different depending upon the number of responses.
The pre-survey consisted of 37 questions and the post survey consisted of 17 questions. Copies of the survey instruments are available from the author. The pre-survey asked questions on the following topics: demographics, oral health knowledge, oral habits and oral health behaviors prior to diagnosis, oral health and habits since diagnosis with AN-BP or BN and current self-perceptions. The post-survey addressed similar issues after the patients participated in the education program. Chi-square analyses were performed to compare those who completed only the pre-survey questionnaire and those who completed both surveys and to assess the effect of age (< 23 vs > =23) and dental visit frequency (regularly vs occasionally/if a problem) on the pre-survey self-perception items. Discordance between pre and post survey responses were analyzed using the McNemar Test or its extension, the Bowken's Test of Symmetry. All analyses were conducted using SAS®v9.4software. Level of significance was set at 0.05 for all analyses. Statistical results were not corrected for multiplicity of comparisons because of the nature of the study.
The study design and all questionnaires, presentations, consents to participate and hand-outs were reviewed and approved by the Institutional Review Boards (IRB) at the University of North Carolina at Chapel Hill (IRB #15-3295). All study sites ceded review responsibility to the UNC-Chapel Hill IRB for management. The study is registered with ClinicalTrials.gov (Identifier: NCT03921632). Funding for this study was provided by the Department of Pediatric Dentistry.

Study population
Patients enrolled in three in-patient treatment programs participated in the study; Center of Excellence for Eating Disorders at the University of North Carolina School of Medicine, Carolina House Eating Disorder Treatment Center, and Veritas Collaborative. Patients between the ages of 13 years old and 50 years old were eligible to participate in the study. While there are now eight recognized classifications of eating disorders in the DSM V [9], this study was limited to patients with anorexia nervosa and bulimia nervosa. Most of the patients who participated in the study did classify themselves as having anorexia nervosa.

Results
Sixty-seven patients were initially screened (92% Caucasian/100% females) and completed the pre-survey questionnaire but only 46 completed both pre-and postquestionnaires and attended all three of the educational module presentations. This was due to the patient being  from the clinic or problems with scheduling return visits. There were no statistically significant differences between those who completed the protocol and those who did not (Table 1).
Of those who completed the protocol, the mean age at the time of diagnosis was 21.4 years (SD = 10.3) and at the beginning of the study 25.2 years old (SD = 10.8). The majority (69%) of the patients had AN-BP. Fiftynine percent reported seeing a dentist regularly but 20% reported seeing a dentist only when they had a dental problem. Only 15% of the patients reported being referred to a dentist since their eating disorder was diagnosed. While most patients knew in advance eating disorders behavior can cause erosion of the teeth (N = 35; 76%) only 30% (N = 14) knew the most likely location in the mouth for erosion to occur. Eight-8 % also reported tooth sensitivity as an oral effect of an eating disorder; 78% reported dry mouth as an effect while 57% thought salivary gland enlargement and 38% oral cancer were possible oral effects ( Table 2).
Before the intervention, there were no statistically significant differences (p > 0.06) in the proportion of positive responses for those less than 23 years of age (54%) compared to those 23 or older (46%) with respect to the effect that the teeth / mouth have on self-perception. Patients who reported going to the dentist regularly were significantly more likely to respond that their teeth/mouth had a positive effect on how they looked to themselves (p = 0.03), how they looked to others (p = 0.03), their general health (p = 0.01), and their general happiness (p < 0.001) than those who only reported going occasionally, or if they had a problem. Positive responses to the effect of the teeth/mouth on kissing and romantic relationships were also significantly higher for those who go to the dentist regularly compared to those who don't (p = 0.04 and 0.002 respectively). Table 2. Sixty-three percent (N = 27) of the patients said they had a plan to use the Smiles Matter material. Only 11% (N = 5) did not plan to see a dentist or would go only if they had a problem while 67% (N = 30) planned to see a dentist within 6 months. After participating in the program, 95 % of the patients (N = 41) correctly identified dental erosion as the most common dental finding of eating disorders. Similarly, 73% (N = 32) after the program answered correctly where erosion is most likely to occur in the mouth (Table 3).

Discussion
Evidence-based communication programs are critical for health professionals managing the prevention, treatment, and post treatment of patients of patients with AN-BP and BN eating disorders. It is important that oral health education programs be included to assist eating disorder patients improve their self-image and shift their focus to the importance of their smile and oral health. The results of this study suggests improved communication and providing appropriate information to AN-BP and BN eating disorder patients will help change behaviors Table 1 Comparison of those who participated in both the pre and the post survey (N = 46) and those who only participated in the pre-survey (N = 21) and improve their oral health. The intent of this study was to survey the effectiveness of an original oral health education program, "Smiles Matter", which aimed to improve patient's oral hygiene practices and oral health knowledge, and provide a supportive environment to empower them to take control of their oral health as well as their general health. Throughout the study, participating patients verbally shared that they had not previously had specialized, preventive oral care or recommendations from their eating disorder treatment team targeted to oral health. It is important that eating disorder patients have access to a dental home to help provide a supportive environment for their oral health, their self-image as it relates to their smile, and their general health. The study found that patients who went to the dentist more frequently had a more positive response to how their teeth affected their lives. It is important for eating disorder treatment centers to provide an oral health educational program and to include an oral health educational program in their treatment protocol.
The primary limitation of this study was the small sample size. It was a challenge to identify patients who were available to complete all components of the study due to the intensity, length, and location of the eating disorder treatment programs. The dropout rate (patients not completing the entire program) was another limiting factor. While additional history was probably recorded in the patient's clinical record (e.g. duration of illness, psychiatric comorbidity) this information was not recorded/analyzed in the present study.

Conclusions
While statistical significance were shown in this study, the need to further understand eating disorder patients' oral health knowledge and perceptions of self-image as it relates to their smile (teeth, mouth) is important to assist in developing a standardized oral health program for eating disorder treatment centers to implement into their daily curricula/protocol. Including an oral health education program in eating disorder treatment centers appears to improve patients' oral hygiene and oral health knowledge, as well as provides a supportive environment to empower the patients to take control of their overall oral health. Whether the initial improvement in oral habits and awareness will be maintained over time could not be determined by this study.