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What are the dental and cutaneous manifestations of eating disorders?

Olusola, Patti MD; Dieu, Ngoc Bich DO; Bracks, Jessica MD; Arendt, Tyler MD; Cook, Matt DO

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doi: 10.1097/EBP.0000000000000361
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Dental erosions, dental caries, and dry mouth are more common in patients with eating disorders compared to controls (SOR: B, meta-analysis of case-control studies). Xerosis, acne, hypertrichosis lanuginose, alopecia, dental caries, lanugo hair, ungula fragility, and Russel's sign are the most common cutaneous manifestations of eating disorders (SOR: C, prospective cohort study).

A 2015 systemic review and meta-analysis of 10 case-control studies investigated associations between eating disorders (anorexia nervosa, bulemia nervosa, and eating disorders not otherwise specified) and poor oral health.1 The search encompassed Medline, PsycINFO, and EMBASE from January 1951 until June 2014. Studies including patients with severe mental illness, intellectual disability, alcohol and substance abuse disorders, and other psychological disease were excluded. The studies included 556 patients with eating disorders and 556 controls. The patients ranged from 10 to 50 years old and 98% were female. Three types of oral pathology were defined as outcomes: dental erosions, dental caries, and dry mouth secondary to salivary gland dysfunction. Oral status determination in all studies was completed by trained dental examiners using standardized indices of the Decayed, Missing, Filled Surfaces Index, or the Decayed, Missing, Filled Teeth Index. Eating disorders were associated with increased odds of dental erosions, caries, and salivary gland dysfunction compared to controls (see TABLE 1). Limitations included suboptimal study quality due to lack of standardization of psychiatric and dental assessments as well as not accounting for possible confounding factors including socioeconomic status, ethnicity, and medical history. Most of the outcomes had an I2 > 50%, indicating significant heterogeneity. There was no evidence of publication bias in the dental erosion outcome and too few trials to assess for publication bias in other outcomes.

Associations between eating disorders and dental pathology from case-control studies1

A 2000 prospective cohort study assessed the prevalence of dermatologic findings in 200 patients recently admitted with an eating disorder.2 Consecutive patients admitted to a single Argentinian hospital, 13 to 35 years old (97% female), were evaluated by dermatologists. In this cohort, 62 patients had anorexia nervosa, 122 had bulimia nervosa, and 16 had eating disorders not otherwise specified. Xerosis, acne, alopecia, dental caries, and Russell's sign (calluses on the knuckles and volar aspect of hand) were the most prevalent skin manifestations (see TABLE 2). This study was limited by the enrollment of only recently admitted patients; however, this was done because the investigators expected increased visibility of skin lesions in this subpopulation.

Prevalence of most common skin manifestations associated with eating disorders2


1. Kisely S, Baghaie H, Lalloo R, et al. Association between poor oral health and eating disorders: systemic review and meta-analysis. Br J Psychiatry. 2015; 207:299–305. [STEP 3]
2. Glorio R, Allevato M, De Pablo A, et al. Prevalence of cutaneous manifestations in 200 patients with eating disorders. Int J Dermatol. 2000; 39:348–353. [STEP 3]
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