What’s Hiding Behind that Smile?
Identifying and addressing patients’ underlying health and social problems
Oral healthcare practitioners are often their patients’ first line of defense and intervention for problems extending beyond the smile. These could involve sleep breathing, eating, and substance-abuse disorders, as well as domestic violence. In some cases, the signs and symptoms are apparent, as in the case of lingual tooth wear and erosion signifying acid reflux or repetitive regurgitation from anorexia or bulimia. The signs could be the soft and almost malleable tooth surfaces and structure often seen concurrent with methamphetamine use (ie, “meth mouth”). In other cases, chipped, fractured, or avulsed teeth resulting from a violent incident may be explained away, leaving the true cause suspect.
From identifying and treating the oral symptoms of eating disorders, to treating patients battling drug addiction, to helping restore the lives of those shattered by domestic violence, today’s oral healthcare profession affords dental team members an opportunity to assume a more significant place in establishing their patients’ overall well-being.
Regrettably, the reported frequency of bulimia nervosa has risen significantly over the past 40 years. As such, the dental team will likely encounter patients battling eating disorders.1 While eating disorders are prevalent among both genders, females tend to have eating disorders more than men.2 Statistics indicate that an estimated 0.5% to 1% of adult women and adolescent girls have anorexia nervosa and 1% to 2% show symptoms of bulimia nervosa. Ten percent of women and young girls show signs of excessive behavior, such as strenuous exercise, consistent dieting, and vomiting, that could eventually lead to an eating disorder.3
Their teeth often display several telltale signs of their disorder, such as wear, erosion, and caries.4 Signs also include xerostomia, enlarged parotid glands, traumatized oral mucosa, and other oral manifestations.5 Often, dental and mental health continues to deteriorate as their disorder progresses if they do not receive proper treatment.4 Therefore, the dental team should be aware of all signs of eating disorders so they can offer advice to patients regarding the disorder and seeking treatment.6
Because eating disorders are disturbances in eating behavior with widespread effects, knowledge of behavioral management of eating disorders is beneficial. Oral care practitioners with this knowledge are better equipped to provide successful dental management, combined with a holistic approach to patient care.7 When it comes to treating anorexia nervosa and bulimia nervosa, highlighting the oral implications is essential. In order to proceed with treatment, many believe patients must receive psychotherapy and stop vomiting first.8
“Our philosophy for the last 40 years has been the opposite. We have intervened for these patients, and when you think about the reality of what happens dentally with an eating disorder patient, they’ve lost all their enamel, the teeth can be very sensitive, abscessed, or fragile, or fracture,” explains Thomas J. Balshi, DDS, PhD, of Pi Dental Implant Center. “They are in pain, and some dentists tell them that in order for them to be treated, they have to be cured of their eating disorder. But how can these patients think of putting food in their mouths to eat when they’re in pain.”
Balshi explains that dental professionals must deal with getting eating disorder patients out of pain and help them regain their self-esteem, which is critically important to the healing process for eating disorder patients. He believes the dental profession’s philosophy needs to take a second look at how it approaches these patients.
Unfortunately, there are no official guidelines to follow for providing support to patients regarding their eating disorder.9 Most dental practices don’t have an action plan for handling patients suspected of having eating disorders, and some fear offending or approaching patients on the subject, or of misdiagnosis.3 While female dentists tend to have more knowledge regarding eating disorders than their male counterparts, they have greater difficulty talking to patients and/or the parents of patients suspected of having an eating disorder than their male peers do.10
“We treat them as any other normal human being, recognizing that they have another problem, but that is something we have to deal with. It’s akin to patients walking through the door who need very sophisticated and advanced dentistry and happen to be post-cancer treatment patients or have had a major cardiac issue,” Balshi says. “There are medical issues that patients come to us with that we must consider, but we need to manage them from a dental perspective.”
Like any other patient, the first thing dentists would do with an eating disorder or any other patient is make a diagnosis. It’s often during the initial or diagnostic visit that dentists discover that the patient has an eating disorder, Balshi elaborates. Sometimes it’s readily apparent clinically, sometimes it’s very subtly apparent, and sometimes patients will readily admit to it.
Most dental professionals aren’t familiar with available referral resources, or what the next step would be in behavior management treatment. Media sources, specifically newspapers and television, are the primary information sources regarding eating disorders, not educational training.10 Additionally, the role of dentists in intervening in eating disorder cases is often diminished and undervalued in the medical community due to a lack of working relationships between the dental and physician communities.3,5
“The severity of this disease is not insignificant. We as professionals really must understand that eating disorders are extremely serious to the point where they can be fatal. We are dealing with a medical issue that has a mortality attached to it that is no different than severe atherosclerosis and coronary artery disease,” Balshi emphasizes. “We can’t ignore these patients, especially if they have not admitted to it and are not under any formal treatment program.”
When drug users become addicts, their need for the drug and getting high supersedes anything else, including dental care. A majority of addicts have poor oral hygiene and extensive dental damage, although the levels of dental disease vary depending on the extent of abuse and type of drug used.11 Studies have shown that the dental effects of drug abuse vary among races. After years of narcotics use, African-American addicts have the least amount of remaining teeth, and African Americans and Hispanics are less likely to use dental services than Caucasian users.12
Rotten teeth, abscesses, dental decay, toothaches, tooth loss, and low saliva secretion are among the oral signs and symptoms of drug abuse, although these conditions certainly have other causes.13 Among the drugs patients may abuse that cause dental problems are cocaine, methamphetamine, ecstasy, and opiates.
Patients abusing cocaine typically present with gingival lesions, tooth surface erosion, and perforation of the nasal septum and palate. Ulceration and atropy of the tissues, direct smearing of the oral mucosa, especially the gingiva, and stimulant effects on the facial and masticatory muscles, may also be present.14
It’s imperative to understand that there are increased risks when performing dental procedures if a patient is under the influence of cocaine, such as a greater increase of a medical emergency specifically when epinephrine-containing local anesthetics or retraction cords are used.14 It is recommended that dentists postpone dental treatments for 6 to 24 hours until patients are no longer under the influence.15
Ecstasy (methylenedioxymethamphetamine) is used by young adults in large metropolitan cities and urban areas.16 Among the many symptoms of ecstasy abuse are xerostomia, bruxism, and a greater likelihood of developing dental erosion. Ecstasy users also can experience depression, panic disorders, psychotic episodes, impulsive behavior, and life-threatening conditions such as liver failure, hyperthermia, and hyponatraemia. Another sign of abuse is changes in the oral mucosa.17
Worldwide, 35 million people are methamphetamine (meth) users. In the United States, 10.4 million people are users, although this number is declining.18 Oral symptoms of meth abuse include dental disease, missing teeth, broken or lose teeth, bruxism, and dentin erosion.19 Other symptoms include black, stained, and rotting teeth. In a majority of cases, teeth are so damaged that they require extraction.20 “Meth mouth,” a specific pattern of oral signs and symptoms indicating meth use, is characterized by excessive caries, tooth fracture, and weakening of tooth structure.21
In terms of opioid abuse, 12% of users have been prescribed the medication to treat a medical ailment, while 23% have taken the drug for non-medical reasons. Dentists could have a significant role in intervening in opioid abuse through patient assessment and education, referring patients to substance abuse treatment, and utilizing prescription-monitoring programs.22
According to Matthew Messina, DDS, consumer advisor for the American Dental Association, it is difficult to determine the percentage of the dental patient population that could benefit from dental professionals’ intervening when they suspect drug abuse. There is a wide variation in the estimates of the percentage of the population believed to have a substance abuse disorder. For someone with a substance use problem, proper intervention and support by their healthcare team would clearly help 100% of these patients, he says.
Although until recently there has been a lack of programs and resources for dental professionals about how to address and treat patients battling drug abuse, there is a call to action within the healthcare community to create programs similar to tobacco-use cessation efforts. These would give oral healthcare workers the resources and tools to help patients regain oral function and reshape their overall image, instilling self-confidence by re-establishing oral health. This step could help patients recover from drug abuse and deconstruct their “drug user” persona.19 Additionally, establishing open lines of communication between the dental and medical communities can greatly facilitate appropriate steps toward ensuring patients battling drug use receive the treatments and care they need.23
“Dentists are encouraged to be knowledgeable about substance use disorders and take this into consideration when planning treatment and prescribing medications,” Messina explains. “Dentists also are encouraged to be familiar with their community’s treatment resources for patients with substance use disorders.”
Unfortunately, addicts typically fear dental practices and facing the scorn and judgment of being “outed” as a drug user.23 When patients suspected of or known to have drug abuse problems do present, it is imperative that dentists and team members recognize their special dental conditions—such as sensitive teeth and low pain tolerance—and try to establish a trusting rapport that acknowledges their need for care.13
“If substance abuse is suspected or a history of substance abuse exists, the dentist is encouraged to seek consultation with the patient’s physician so that a team approach to treatment can occur,” Messina emphasizes. “We have to discuss our concerns about drug abuse with the patient, but if they refuse to allow us to discuss our concerns with others, the dentist may be constrained by state and federal law. It’s a tricky situation.”
An estimated 1.5 million women in the United States sustain serious injury from sexual or physical assault, and it’s been reported that more than 50% of female homicides result from domestic violence.24
In every state, physicians and dentists have a legal obligation to report suspected cases of child abuse and neglect to social services or law enforcement agencies.25 However, only some states require suspected cases of domestic violence to be reported. For most dentists it’s a personal choice to report domestic violence to authorities.26
Most domestic violence victims show indications of abuse and want their dental team to recognize the signs and provide assistance and referrals for help and treatment. The most universal target of domestic abuse is the face, and strangulation is a serious indicator of severe domestic violence that is usually disregarded.27,28
However, according to Kenneth L. Banks, DDS, a dentist who participates in the American Academy of Cosmetic Dentistry’s (AACD) Give Back a Smile Program, dental issues from domestic violence do not only involve trauma. Decay, decalcification, and damage also occur from neglect as a result of emotional abuse and the victim being unable or allowed to seek appropriate dental care.
Several other signs indicate child abuse or neglect, including bite marks, perioral and intraoral injuries, infections, and diseases, as well as caries, gingivitis, contusions, burns, lacerations of the tongue, lips, buccal mucosa, soft and hard palate, alveolar mucosa, fractured or displaced teeth, or jaw and bone fractures.25 Other signs are discolored teeth, bruises, scarring at the corner of the mouth, posterior pharyngeal injuries, and retropharyngeal abscesses.25
The dental team can create a safe and secure place for victims. Concurrently, dental offices also can be equipped to inform patients about local resources, recommend strategies to promote safety, provide supportive messages, and educate patients about the effects of abuse to overall and dental health.29
To begin, the AVDR (ie, asking, validating, documenting, and referring) tool can facilitate communication with patients on an appropriate level to ensure they receive the best possible care. Dental team members ask the patient about the injury or accident, provide validating messages about the wrongs of battering and reinforce that the victim is not at fault, document the signs and symptoms as well as anything the patient has said or done while communicating about the incident, and finally refer the patient to a domestic violence specialist. It is important for oral care practitioners to remember that it is not their responsibility to solve the problem for their patient.26
“There’s a fine line. The patient would have to open up at some point and tell the dentist there’s been trauma,” explains Banks. “We can ask questions, but they have to open up at some point. If it wasn’t a Give Back a Smile patient, then there are agencies that dentists could refer them to and help them obtain the assistance they need.”
While dentists can treat the oral complications stemming from child abuse and neglect, the biggest form of treatment they can provide is reporting all signs of abuse for investigation. Because abuse is not contingent upon one body area, dentists and physicians should have a good “working relationship” so they may confer about how to treat a patient and provide the best possible overall care.25
Several organizations provide guidelines, support, and information for dental professionals about addressing potential cases of abuse, neglect, and domestic violence. The American Academy of Pediatrics has established guidelines and information for the medical community regarding child abuse and/or neglect examinations called “Guidelines in the Evaluation of Sexual Abuse of Children.”25 Prevent Dental Abuse and Neglect Through Dental Awareness (PANDA) is a coalition working to train and educate nurses, physicians, dentists, dental auxiliaries, teachers, and childcare providers to recognize signs of suspected abuse, talk to individuals, and take the next steps in getting help for the victim.25 The American Board of Forensic Odontology (ABFO) has created a photographic scale to document a patient’s patterned injuries.25
Once intervention has already taken place, and the patient is removed from the violent relationship and has broken ties with the abusive partner, programs like Give Back a Smile help them restore their smiles—and their lives—at no cost to them, explains Banks, who has treated three domestic violence survivors in his area. Banks says he and many AACD members rely on agencies like the AACD and the Give Back a Smile Program to get involved and serve as a main resource for domestic violence cases.
“Every case is different because every individual is different,” Banks admits. “The biggest common issue I see is that the patient’s self-esteem is low and they don’t feel worthy of anything. As you treat them, their personality changes, their self-esteem starts coming back, and they feel more worthwhile and grateful, and you see the person change right before your eyes.”
Regardless of the specific cause of the problem that drove the patient to seek dental care, when faced with individuals who present with problems that extend beyond the smile, dental professionals are challenged to understand the boundaries governing their intervention and the limits of what their skills and talents can accomplish.
Balshi asserts that dentists are obligated as medical professionals to encourage patients who won’t admit to their eating disorders—a disease with mortality attached to it—to seek additional treatment. He says the bottom line is that once dentists have established the knowledge factor that an individual has an eating disorder, they need to be involved in recommending adjunctive care.
“Substance abuse is a difficult issue in society as a whole, and the challenges that we have as dentists mirror these problems,” Messina says. “We care deeply about our patients’ health and well-being, but there are limits to what we can do to help people help themselves. If a patient is seeking help, we can be invaluable as a resource and support system for them. If they do not want help, there is little we can do to force it on them.”
Fortunately, there are resources and specific support mechanisms that can guide oral healthcare workers in treating and referring patients to other agencies and professionals so that an individual’s overall well being is properly managed. In other cases, the dental team can be the ideal first line of defense, treatment, and intervention.
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National Association of Anorexia
Nervosa and Associated Disorders
National Institute on Drug Abuse
National Resource Center on Domestic Violence
National Coalition Against Domestic Violence