Eating disorders (ED) are complex psychiatric conditions that severely impact individuals’ physical health, emotional well-being and quality of life(1). According to the American Psychiatric Association(1), ED encompass a range of behaviours centred around dysfunctional eating habits and attitudes toward body weight and shape. The main categories, as outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), include anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED) and other specified feeding and eating disorders (OSFED)(Reference Micali2). These conditions lead to physical, mental and social impairments and are associated with the highest rates of cause-specific mortality among mental health conditions(Reference Arcelus, Mitchell and Wales3,Reference Samnaliev, Noh and Sonneville4) ; compared with individuals without ED, those affected experience reduced employment participation, increased absenteeism and presenteeism, higher healthcare and informal care costs and lost lifetime earnings for those who die prematurely(Reference Santomauro, Melen and Mitchison5). The diagnosis of ED involves a comprehensive assessment that includes psychological, behavioural and physiological criteria(Reference Arcelus, Mitchell and Wales6). Clinicians use the DSM-5 criteria, which emphasise patterns of disordered eating, intense fear of weight gain and undue influence of body image on self-worth(1). Psychological assessments often reveal comorbidities, such as anxiety or depression, which further complicate treatment(Reference Hambleton, Pepin and Le7). Diagnostic tools may also include physical examinations, laboratory tests and nutritional assessments to evaluate the extent of malnutrition and its physiological impact(Reference Prieto8).
Currently, ED represent a significant public health issue, with increasing prevalence globally(Reference Silén and Keski-Rahkonen9). It has been recently reported that among 12 mental health disorders, ED have experienced the second largest absolute increase in incidence, with age-standardised rates rising from 175·83 per 100 000 in 1990 to 216·02 per 100 000 in 2019, surpassed only by depressive disorders(Reference Micali10).
The global burden of ED increased across all countries, independent of levels of the socio-demographic index; from 1990 to 2019, the disability-adjusted life-years increased for ED across all world regions, particularly in South, East and Southeast Asia(Reference Micali10). The burden on public health is also exacerbated by the associated healthcare costs, long-term treatment requirements and the impact on productivity and social welfare(Reference Streatfeild, Hickson and Austin11). In addition, there is a noted stigma surrounding ED, which often hinders early diagnosis and intervention, further complicating public health efforts aimed at prevention and treatment(Reference Brelet, Flaudias and Désert12).
Among the ED contributing to the rising incidence, AN stands out due to its severity, chronic course, and substantial impact on individuals and healthcare systems(Reference Auger, Potter and Ukah13). AN affects an estimated 1–4 % of women, with peak onset typically occurring between the ages of 14 and 17(Reference Said, Sengun Filiz and Stringer14). In 2019, the years of life lost attributable to AN were calculated at 1674·95(Reference Micali10), reflecting its substantial impact on public health. AN is frequently comorbid with depressive disorders, anxiety disorders, as well as obsessive-compulsive disorder(Reference Tan, Raut and Le15), adding to the overall disease burden and placing a significant emotional toll on families and caregivers. The disorder often follows a chronic course, leading to long-term disability; notably, it has been recently reported(Reference Eddy, Tabri and Thomas16) that only about 30 % of individuals with AN achieved recovery after nine years.
BN, another well-documented ED, is characterised by recurrent episodes of binge eating followed by compensatory behaviours such as self-induced vomiting (SIV) or laxative misuse(1). Individuals with BN usually maintain a normal body weight but exhibit pronounced self-criticism and distorted self-evaluation based on body image(Reference Clemente-Suárez, Ramírez-Goerke and Redondo-Flórez17). These psychological features are closely tied to self-esteem and social functioning. Regionally and nationally, the burden of BN has been found to correlate positively with socio-economic development levels(Reference Ge, Zhang and Li18). Although females generally bear a higher burden of BN, recent trends show that males are experiencing faster growth rates in diagnosed cases. Projections indicate that, compared with 2021, the age-standardised incidence rate of BN will increase slightly by 2030 in both sexes, with a marginally greater rise in males (0·76 %) than in females (0·24 %)(Reference Ge, Zhang and Li18).
Until 2019, AN and BN were the only ED recognised as contributors to the global burden of disease(Reference Santomauro, Melen and Mitchison5). This was largely due to the historical focus of epidemiological studies on these two disorders, often overlooking others such as binge BED and OSFED, which were formally added to diagnostic classification systems only in 2013, having previously been included under the DSM-IV category of ED not otherwise specified (EDNOS)(Reference Santomauro, Melen and Mitchison5). BED is characterised by the compulsive consumption of large amounts of food, often accompanied by a sense of loss of control but without compensatory behaviours to prevent weight gain(1). BED is closely linked to conditions such as obesity, hypertension, type 2 diabetes and CVD, which significantly impact both physical health and the overall healthcare burden(Reference Villa, Connell and Abati19). OSFED encompasses several distinct syndromes and includes atypical or subclinical forms of ED, with symptoms that do not fully meet the diagnostic criteria of other ED(Reference Chevinsky, Wadden and Chao20). Research indicates that BED and OSFED are among the most prevalent ED, with up to half of individuals in treatment for an ED diagnosed with either BED or OSFED(Reference Santomauro, Melen and Mitchison5).
The multifaceted nature of ED necessitates a multidisciplinary approach involving healthcare professionals from psychiatry, psychology, nutrition and other relevant fields such as oral health practitioners(Reference Monteleone, Fernandez-Aranda and Voderholzer21,Reference Chirravur, Chirravur and Gopi-Firth22) .
The WHO defines oral health as the condition of the mouth, teeth and orofacial structures that allow individuals to perform essential functions such as eating, breathing and speaking, and includes psychosocial dimensions such as self-confidence, well-being and the ability to socialise and work without pain, discomfort and embarrassment(23). Integrating dental and oral health professionals into the treatment framework is particularly crucial, as ED are often associated with oral pathologies, including dental erosion, xerostomia, periodontal disease and dental caries(Reference Nijakowski, Jankowski and Gruszczyński24). These pathologies result from malnutrition, acid erosion due to vomiting and neglect of oral hygiene, which can compound the individual’s health complications(Reference Hasan, Ahmed and Panigrahi25).
As for ED, untreated oral diseases affect half of the world’s population and share determinants and risk factors with other most common non-communicable diseases, globally impacting approximately 3·5 billion people across diverse age groups, increasing, particularly in low- and middle-income countries(26). The WHO Commission on the Social Determinants of Health has emphasised the importance of socio-economic, political and environmental health factors exposed to individuals throughout their lives and recognised the need to prioritise oral health within global health agendas(Reference Santomauro, Melen and Mitchison5).
Early detection and intervention are critical for recovery from ED; thus, dental practitioners play an essential role in the recovery process, as they are often the first health professionals to identify signs and symptoms of disordered eating. Given the vital role oral health care providers can have in the early identification, referral and case management of patients with ED, they must acquire comprehensive knowledge of the oral complications associated with these disorders(Reference DeBate, Tedesco and Kerschbaum27).
Building upon the preceding considerations, this narrative review aims to elucidate the intricate relationship between various ED, including AN, BN, BED and OSFED, and a range of oral health complications such as dental erosion, gingivitis, cavities, burning tongue, difficulty in plaque control, tooth sensitivity, increased vulnerability to bacterial colonisation, xerostomia and altered saliva composition. Specifically, recognising the transdiagnostic nature of ED, wherein individuals may transition across diagnostic categories over time(Reference Fairburn, Cooper and Shafran28), the review seeks to identify the behavioural and physiological mechanisms that underpin oral health complications in populations affected by ED. By adopting a risk-factor-oriented approach, this review intends to clarify how shared and disorder-specific behaviours contribute to the deterioration of oral structures and functions, to inform clinical practice and enhance multidisciplinary prevention and treatment strategies.
Approach to literature selection and thematic data synthesis
This narrative review was conducted by identifying, selecting and synthesising peer-reviewed literature on the oral health consequences of ED. Given the considerable diagnostic overlap and frequent shifts in clinical presentation observed in individuals with ED, the analysis was structured around transdiagnostic behavioural and physiological risk factors, rather than being organised solely by diagnostic category. Although this is not a systematic review, a structured approach was employed to ensure coherence in both the selection of the literature and the presentation of findings.
The thematic organisation by behavioural and physiological risk factors was designed to enhance interpretability and provide a comprehensive understanding of the multifaceted relationship between ED and oral health. Therefore, searches were conducted in the electronic databases PubMed and Web of Science using the following keywords in various combinations: ‘oral health’, ‘eating disorders’ (including specific types such as ‘anorexia nervosa’, ‘bulimia nervosa’ and ‘binge eating disorder’), ‘dental caries’ and ‘dental erosion’; Boolean operators (AND; OR) were also applied to refine the search strategy.
Studies included in the review met specific inclusion criteria: including individuals with ED diagnoses and without age restriction, published in the English language within the last 24 years (2000–2024). Exclusion criteria encompassed in vitro and in vivo studies; non-English studies conducted before 2000; systematic reviews and meta-analyses, case series and narrative reviews.
A total of 700 studies were initially identified. After applying filters, 223 studies were excluded, leaving 477 for further evaluation. From these, 425 studies were excluded following a detailed review. Of the remaining fifty-two potentially relevant articles, twenty were excluded due to unmet inclusion criteria. A final assessment of thirty-two articles led to the exclusion of ten more, resulting in twenty-two articles included in the review.
The results presented in the selected studies were then thematically grouped into the following four domains, according to behavioural and physiological risk factors (Table 1)
-
(i) Caloric restriction and malnutrition(Reference Johansson, Norring and Unell29–Reference Johansson, Mjanger Øvretvedt and Reinholtsen34,Reference Shaughnessy, Feldman and Cleveland36–Reference Garrido-Martínez, Domínguez-Gordillo and Cerero-Lapiedra40)
-
(ii) Purging behaviours: Vomiting, laxatives and diuretics(Reference Johansson, Norring and Unell29,Reference Uhlen, Tveit and Stenhagen31,Reference Lourenço, Azevedo and Brandão33–Reference Dynesen, Bardow and Petersson35,Reference Chiba, Sumida and Moimaz37,Reference Panico, Piemonte and Lazos41–Reference Manevski, Stojsin and Vukoje48)
-
(iii) Binge eating episodes(Reference Johansson, Norring and Unell29,Reference Uhlen, Tveit and Stenhagen31,Reference Johansson, Mjanger Øvretvedt and Reinholtsen34)
-
(iv) Oral hygiene neglect(Reference Shaughnessy, Feldman and Cleveland36,Reference Pallier, Karimova and Boillot49,Reference Mazurek, Szyszkowska and Mazurek50)
Table 1. List of studies grouped according to pathogenic mechanisms that transcend specific ED diagnoses
This thematic organisation was adopted to reduce redundancy and to highlight shared pathogenic mechanisms that transcend specific ED diagnoses. Relevant findings from studies on AN, BN, BED and OSFED (Table 2) were redistributed in the text within these categories without modifying the original scientific content.
Table 2. Studies describing the association between ED and oral disorders
ED, eating disorders; AN, anorexia nervosa; BN, bulimia nervosa; BED, binge eating disorder; EDNOS, eating disorder not otherwise specified; OSFED, other specified feeding and eating disorder; DSM, diagnostic and statistical manual of mental disorders; DMF, decay-missing-filled; EDI-2, Eating Disorder Inventory-2; VPI, visible plaque index; GBI, gingival bleeding index; DMFT, decayed, missing and filled teeth; DMFS, Decayed, missing, or filled surfaces; BEWE, Basic Erosive Wear Examination; UWS, unstimulated whole salivary; SWS, stimulated whole saliva; UKU, Udvalg for Kliniske Undersogelser; OHI-S, simplified oral hygiene index; GI, modified gingival index; BMD, bone mineral density; MCW, mandibular cortical width; TWI, tooth wear index; SIV, self-induced vomiting; VEDE, visual erosion dental examination; M.I.N.I., Mini International Neuropsychiatric Interview; PI, plaque index; BOP, bleeding on probing; CPI, community periodontal index; OHIP, oral health impact profile; OHRQoL, oral health-related quality of life; ALT, alanine aminotransferase, AST, aspartate aminotransferase; LDH, lactate dehydrogenase; TBARS, thiobarbituric acid reactive substance; PCR, plaque control record; GERD, gastroesophageal reflux disease; BMS, burning mouth syndrome; NSSF, non-stimulated salivary flow; DAI, dental aesthetic index; TMD, temporomandibular disorder; AMO, active mouth opening; PMO, passive mouth opening.
Finally, a dedicated section was included to examine the role and clinical approach of dental professionals in the context of ED (v. Dental Professionals’ Role and Approach). Particularly, emphasis was placed on the relevance of early-stage identification, highlighting how specific oral health assessments, such as enamel erosion, xerostomia and alterations in salivary flow and composition, may serve as early clinical indicators of ED onset. Furthermore, attention was given to the duration of illness when such data were available in the original studies, to explore potential correlations between disease progression and oral health outcomes.
Caloric restriction and malnutrition
Caloric restriction is a hallmark behaviour in ED, particularly AN, where prolonged limitation of energy intake is driven by an intense fear of weight gain and a distorted body image(Reference Wani, Chakole and Agrawal51). This leads to deficiencies in macronutrients and micronutrients, disrupting metabolic and physiological functions and causing immune, hormonal and organ impairments(Reference Wani, Chakole and Agrawal51).
Malnutrition is worsened by increased physical activity, purging behaviours and gastrointestinal issues that reduce nutrient absorption, ultimately leading to muscle wasting, bone loss, cardiovascular problems and other severe health risks(Reference Moore and Bokor52).The caloric and nutritional deficits associated with AN lead to severe physical health complications, including growth retardation, osteopenia, amenorrhoea, renal insufficiency, abnormal laboratory values and dysfunctions in cardiac and thyroid systems(Reference Said, Sengun Filiz and Stringer14). The leading causes of death in individuals with AN are sudden cardiac death due to ventricular arrhythmias and suicide(Reference Said, Sengun Filiz and Stringer14); overall, mortality rates in AN are nearly six times higher than those in the general population(Reference Schmidt, Adan, Böhm and Campbell53).
AN is strongly associated with a wide range of oral health complications, largely stemming from malnutrition caused by chronic caloric restriction and resulting nutritional deficiencies(Reference Rangé, Pallier and Ali54), such as calcium, vitamin D and protein, which are critical for maintaining dental and periodontal health(Reference Sanavia and Genovesi55). These nutritional deficits can contribute to weakened enamel, delayed dental development and increased susceptibility to periodontal disease(Reference Botelho, Machado and Proença56). For instance, as reported by Johansson et al. (Reference Johansson, Norring and Unell29), patients with ED, including AN, experienced significantly higher ORs for oral-related complications (OR = 4·1) such as burning tongue (OR = 14·2), dry or cracked lips (OR = 9·6), dental erosion (OR = 8·5) and reduced gingival bleeding (OR = 1·1), when compared with healthy controls. These findings were further confirmed by diverse studies included in this narrative review(Reference Uhlen, Tveit and Stenhagen31–Reference Johansson, Mjanger Øvretvedt and Reinholtsen34,Reference Shaughnessy, Feldman and Cleveland36–Reference Chiba, Chiba and Moimaz39) . Notably, as most oral health clinical trials have focused on adult female patients, Paszynska et al. (Reference Paszyńska, Hernik and Slopien38) conducted a case–control study to investigate AN in younger individuals (<18 years old). They assessed dental health and gingival inflammation in a sample of 117 female adolescents diagnosed with the severe restrictive subtype of AN, comparing the results to those of a control group(Reference Paszyńska, Hernik and Slopien38). The study found that adolescents with AN exhibited poorer dental health than the controls, as indicated by a significantly higher decayed, missing and filled teeth score (P = 0·005); more severe erosive tooth wear (BEWE, P < 0·001); greater difficulty in plaque control (plaque control record, P < 0·001) and higher rates of gingival inflammation (bleeding on probing, P < 0·001); as well as a significant (P < 0·05) associations between gingival bleeding and erosive wear, plaque control record, decayed teeth and filled teeth with disease duration(Reference Paszyńska, Hernik and Slopien38). Identifying oral health issues associated with AN in adolescents is crucial due to the numerous dental complications that may arise with the restrictive subtype of the disorder since adolescence is a key period during which the onset of AN can lead to specific oral health issues, including an increased risk of dental caries, early stages of erosive tooth wear, gingival inflammation and difficulties in maintaining proper dental hygiene(Reference Paszyńska, Hernik and Slopien38). Early detection of these oral health problems can help prevent the progression of dental and periodontal conditions, which can otherwise contribute to further health complications and reduced quality of life in young patients with AN.
Reduced saliva production is another common effect of AN, arising from both malnutrition and dehydration, impairing the mouth’s inherent defence mechanisms against bacterial proliferation and heightening the vulnerability to dental caries and oral infections(Reference Paszynska, Schlueter and Slopien32). In the present review, three studies(Reference Paszynska, Schlueter and Slopien32,Reference Lourenço, Azevedo and Brandão33,Reference Chiba, Sumida and Moimaz37) evaluated alterations in salivary biochemical parameters and flow rate, and oral health-related quality of life in patients with ED, including AN. Paszynska, et al. (Reference Paszynska, Schlueter and Slopien32). conducted a clinical case-control study on twenty-eight female adolescents with AN and thirty-eight age-matched controls, describing that salivary flow rates, both stimulated and unstimulated, were significantly lower in the AN group compared with controls (P = 0·0005 and P = 0·0001, respectively) and individuals with AN exhibited differences in the salivary enzyme activity of collagenase and aspartate aminotransferase activities in stimulated saliva (P < 0·05). The findings supported the hypothesis that reduced salivary flow may be a reliable indicator of AN, as patients exhibited decreased gland activity in both unstimulated and stimulated saliva(Reference Paszynska, Schlueter and Slopien32). Although key salivary enzymes maintain physiological activity despite malnutrition, the reduced salivary output likely lowers their overall concentration, indicating a partial physiological adaptation to severe malnutrition(Reference Paszynska, Schlueter and Slopien32). Similar findings were reported by Deghan et al. (Reference Dehghan, Tantbirojn and Harrison30), who, although not distinguishing among different ED, suggested that extensive tooth erosion in ED may be associated with low stimulated salivary flow, a result consistent with earlier studies by Lourenco et al. (Reference Lourenço, Azevedo and Brandão33) and Chiba et al. (Reference Chiba, Sumida and Moimaz37).
Purging behaviours: vomiting, laxatives and diuretics
Purging behaviours, including SIV, laxative and diuretic abuse, are common compensatory strategies observed across several ED. These behaviours are especially prevalent in BN and in AN, particularly the binge-eating/purging subtype, contributing to severe medical complications and nutritional imbalances(Reference Botelho, Machado and Proença56). The frequent exposure to stomach acid from vomiting erodes dental enamel, particularly on the inner surfaces of the teeth, leading to dental erosion; the acid exposure not only weakens enamel but also increases tooth sensitivity and the likelihood of dental fractures(Reference Panico, Piemonte and Lazos41). Over time, erosion can cause significant structural damage, contributing to functional impairment and aesthetic concerns(Reference Reas and Rø57). In this context, Otsu et al. (Reference Otsu, Hamura and Ishikawa43) investigated the relationship between the severity of dental erosion and behaviours in individuals with ED, particularly focusing on daily diet and vomiting, in a sample of seventy-one patients (including those with AN). The study found that dental erosion was present in 86 % of patients who induced vomiting and significant differences were observed between those with mild and severe erosion, particularly regarding post-vomiting oral hygiene practices(Reference Otsu, Hamura and Ishikawa43). Patients with mild erosion were more likely to drink large amounts of water before vomiting, while those with severe erosion more frequently consumed carbonated beverages or sweetened foods(Reference Otsu, Hamura and Ishikawa43). The authors concluded that the severity of dental erosion in patients with ED is influenced by vomiting-related behaviours and the habitual consumption of specific foods and beverages(Reference Otsu, Hamura and Ishikawa43).
Again, SIV or excessive AN, combined with reduced salivary flow, poor oral hygiene and nutritional deficiencies, further weakens the oral mucosal defences, making the mouth more susceptible to infections(Reference Hasan, Ahmed and Panigrahi25); vomiting exposes the oral cavity to gastric acid, which can erode tooth enamel, leading to dental erosion and increased vulnerability to bacterial colonisation(Reference Uhlen, Tveit and Stenhagen31). Esteves et al. (Reference Esteves, Freitas and Campos45) conducted a cross-sectional, case-control study to investigate the prevalence of oral Candida species in individuals with ED, including AN. The authors concluded that alterations in the natural oral and gut microbiota, particularly due to purgative behaviours, may predispose patients to the acquisition of non-albicans species, such as C. glabrata (commonly found alongside C. albicans in oropharyngeal candidiasis), C. parapsilosis (often isolated from the subungual space of human hands) and C. dubliniensis (a normal component of the upper respiratory tract flora). Unlike C. albicans, these species may contribute to the development of oral candidiasis in individuals with ED(Reference Esteves, Freitas and Campos45).
BN is strongly associated with oral health issues, primarily due to the recurrent SIV and dietary habits associated with the disorder(Reference Panico, Piemonte and Lazos41).
Over time, acidic exposure weakens the enamel, leading to dental erosion, increased tooth sensitivity and a higher risk of cavities(Reference Lourenço, Azevedo and Brandão33,Reference Johansson, Mjanger Øvretvedt and Reinholtsen34) . Among the studies included in this narrative review, Manevsky et al. (Reference Manevski, Stojsin and Vukoje48) investigated the presence, localisation and severity of dental erosion using the Basic Erosive Wear Examination (BEWE) index and assessed the decayed, missing and filled teeth index in thirty patients purging BN and thirty healthy controls. The study employed both questionnaires and clinical examinations to collect data(Reference Manevski, Stojsin and Vukoje48); the results revealed that dental erosion was significantly more prevalent and severe in patients with purging BN compared with controls (P < 0·05), particularly on the oral surfaces of the teeth which were most affected, showing significant wear and thinning of the enamel(Reference Manevski, Stojsin and Vukoje48). However, at the same time, the decayed, missing and filled teeth index values did not differ significantly between the two groups (P = 0·461)(Reference Manevski, Stojsin and Vukoje48).
In individuals with BN, salivary glands may also swell due to chronic vomiting, leading to a visible enlargement of the glands near the jaw, giving the face a swollen appearance(Reference Anitha, Abdulaziz Alhussaini and Ibrahim Alsuwedan58). Besides, repeated acid exposure can alter the composition of saliva, reducing its protective properties and promoting a dry mouth environment, which can increase the likelihood of dental decay, halitosis and infections(Reference Corega, Vaida and Festila59). Among the studies examined, Dynesen et al. (Reference Dynesen, Bardow and Petersson35) analysed the impact of BN on the functionality of the salivary glands and the correlation with dental erosion. This case–control study, evaluating twenty female subjects diagnosed with BN according to the DSM-IV and twenty healthy subjects, reported that unstimulated whole saliva flow was significantly lower in the BN group compared with controls (P = 0·007), with the frequency of SIV and binge eating having no impact on the unstimulated whole saliva flow rate(Reference Dynesen, Bardow and Petersson35). The duration of the ED was inversely related to the salivary flow rate (P = 0·019) in the BN group, and hyposalivation (unstimulated whole saliva ≤ 0·1 ml/min) was more common in the BN group, as patients reported a significantly greater sensation of dry mouth (P = 0·003)(Reference Dynesen, Bardow and Petersson35). Additionally, oral dryness and dental erosion were significantly more pronounced in the BN group (P = 0·003 and P = 0·019, respectively), with a significant correlation between the duration of the ED and the severity of dental erosion (P = 0·007)(Reference Dynesen, Bardow and Petersson35). Similar conclusions were also reported by studies included in the present review(Reference Paszyńska, Słopień and Węglarz42,Reference Blazer, Latzer and Nagler44,Reference Manevski, Stojsin and Vukoje48) .
At the same time, an interesting cross-sectional study conducted by Blazer et al. (Reference Blazer, Latzer and Nagler44) examined the salivary composition and taste perception in twenty-six female patients with BN, and 26 were well-matched for age and BMI controls, starting from the a priori hypothesis that changes in either taste perception or salivary composition might be associated with the active disease. In this context, examinations showed an overall disturbed salivary and taste profile in patients, who complained of xerostomia (dry mouth, P < 0·003) and taste aberration or oral burning sensation (P < 0·016)(Reference Blazer, Latzer and Nagler44). Based on the findings of this study, the authors speculated that disturbances in salivary and taste profiles in patients with BN, regardless of the underlying mechanism, could serve as valuable diagnostic tools and enhance understanding of the disease’s pathogenesis, as these disruptions may potentially trigger or exacerbate the ED(Reference Blazer, Latzer and Nagler44). However, due to the lack of a significant correlation between these disturbances and clinical manifestations, as well as the small and heterogeneous patient sample, further research with larger cohorts is necessary to determine whether these disturbances normalise with recovery(Reference Blazer, Latzer and Nagler44). If normalisation occurs, therapeutic interventions such as antioxidants, anti-inflammatory drugs and saliva substitutes – administered both locally and systemically – should be considered for individuals with BN(Reference Blazer, Latzer and Nagler44).
Again, regarding the salivary composition, Chiba et al. (Reference Chiba, Sumida and Moimaz37), in a quantitative cross-sectional study, investigated periodontal health, alterations in salivary biochemical parameters and oral health-related quality of life in patients with ED, including BN (thirty women with ED v. 30 women as healthy controls). Data showed that the ED group had markedly higher salivary concentrations of total protein (P = 0·0109), aspartate aminotransferase (P = 0·0108), alanine aminotransferase (P = 0·0455) and lactate dehydrogenase (P = 0·0252) than controls, while no differences were found in salivary thiobarbituric acid reactive substance levels(Reference Chiba, Sumida and Moimaz37). Furthermore, Aframian et al. (Reference Aframian, Ofir and Benoliel46) in a cross-sectional and case–control study, compared the pH of oral mucosa of healthy subjects to individuals with gastroesophageal reflux disease, BN and burning mouth syndrome(Reference Aframian, Ofir and Benoliel46). In this case, both the BN and gastroesophageal reflux disease groups demonstrated significantly lower pH levels (6·38 ± 0·45 and 6·51 ± 0·32, respectively) compared with the control group (6·8 ± 0·33)(Reference Aframian, Ofir and Benoliel46). The present narrative review included six studies involving subjects with EDNOS(Reference Johansson, Norring and Unell29,Reference Uhlen, Tveit and Stenhagen31,Reference Johansson, Mjanger Øvretvedt and Reinholtsen34,Reference Panico, Piemonte and Lazos41,Reference Otsu, Hamura and Ishikawa43,Reference Emodi-Perlman, Yoffe and Rosenberg47) ; among them, the only study in which the oral health characteristics of subjects with EDNOS can be described is the study by Panico et al. (Reference Panico, Piemonte and Lazos41), as the other studies do not discriminate between EDNOS and other ED. Therefore, this prospective case-control study aimed at describing oral lesions in women with ED (n 65), also including subjects with EDNOS (n 13), together with subjects with AN (n 6), as well as BN (n 46). In particular, the presence of all oral lesions combined was associated with purging behaviours (OR = 6, 95 % CI = 1·06, 34·12, P = 0·0414) and labial erythema was more frequent in individuals with BN than in those with AN or EDNOS (P = 0·0098) and linked to SIV (OR 4, 95 % CI 1·08, 14·77, P = 0·0396) and diuretic/laxative use (OR 7·89, 95 % CI 2·18, 28·56, P = 0·0012)(Reference Panico, Piemonte and Lazos41). However, the oral examination revealed that 43 % of the patients with EDNOS displayed exfoliative cheilitis and an orange-yellow palate(Reference Panico, Piemonte and Lazos41); additionally, haemorrhagic lesions and instances of cheek or lip biting were observed(Reference Panico, Piemonte and Lazos41).
Binge eating episode
Binge eating episodes, characterised by the compulsive consumption of large amounts of food within a discrete period accompanied by a sense of loss of control, are commonly described in both BN and BED(1). In BN, these episodes are typically followed by compensatory behaviours such as SIV, laxative or diuretic abuse, whereas in BED, compensatory behaviours are absent(1). Both disorders share the common behaviour of excessive intake of carbohydrate-rich, sugary and acidic foods during binge episodes, which have significant implications for oral health. Although data specifically focusing on BED in the context of oral health remain limited – Uhlen et al. (Reference Uhlen, Tveit and Stenhagen31) included only one patient with BED in their cohort – the interplay between binge eating episodes and oral pathology is relevant across both BN and BED populations. The frequent consumption of cariogenic and acidic foods leads to repeated acid attacks on dental enamel, increasing the risk of dental erosion and caries development(Reference Johansson, Norring and Unell29). The acids naturally present in foods consumed during binge episodes (such as fruit juices and citrus fruits) can contribute to enamel demineralisation and erosion(Reference Studen-Pavlovich and Elliott60). While dental erosion affecting the palatal surfaces is more commonly associated with vomiting, buccal and facial surfaces may also be affected in patients who consume excessive amounts of acidic foods, particularly raw fruits with high acid content(Reference Studen-Pavlovich and Elliott60). This repeated exposure to sugars and acids disrupts the oral environment, fostering demineralisation and weakening of enamel, thus increasing tooth sensitivity and vulnerability to structural damage. Johansson et al. (Reference Johansson, Mjanger Øvretvedt and Reinholtsen34) investigated binge eating and SIV behaviours in individuals with ED, reporting that in fourteen out of seventeen cases, binge eating preceded vomiting episodes. The binge episodes typically involve high-calorie, sugar- or fat-rich and acidic foods and drinks, which exacerbate oral acid exposure and enhance enamel erosion and caries risk(Reference Johansson, Mjanger Øvretvedt and Reinholtsen34). Among individuals with ED, those with BED appear to be particularly susceptible to an increased risk of dental caries. This may be due to the frequent intake of high-calorie, carbohydrate-dense foods, often consumed in large quantities and at high frequency throughout the day. A higher frequency of food intake throughout the day may lead to an augmented risk of developing dental caries(Reference Studen-Pavlovich and Elliott60). Moreover, repeated binge eating and compensatory vomiting can result in soft tissue injuries, including trauma to the oral mucosa and pharyngeal tissues. These injuries may stem from the mechanical stress of rapid food intake(Reference Studen-Pavlovich and Elliott60). Within-group analyses showed that ED patients with present vomiting and/or binge eating behaviours perceived their oral health as significantly worse (OR = 6·0) and exhibited a higher risk of dental erosion (OR = 5·5) compared with those without such behaviours(Reference Johansson, Norring and Unell29).
Oral hygiene neglect
Poor oral hygiene may further exacerbate the oral health complications associated with ED, acting as an additional and often overlooked risk factor(Reference Inchingolo, Dipalma and Azzollini61). Individuals with ED, particularly those with AN or BN, frequently experience a combination of psychological distress, social withdrawal and physical fatigue that can lead to the neglect of routine oral hygiene practices and avoidance of regular dental check-ups(Reference Inchingolo, Dipalma and Azzollini61). This neglect, compounded by the systemic effects of malnutrition or repeated exposure to gastric acid in purging behaviours, creates a synergistic effect that accelerates the deterioration of oral tissues(Reference Inchingolo, Dipalma and Azzollini61). For example, inadequate plaque control and prolonged exposure to acidic environments can hasten enamel erosion, exacerbate gingival inflammation and increase the risk of caries and periodontal disease(Reference Paszyńska, Hernik and Slopien38,Reference Pallier, Karimova and Boillot49) . Moreover, the stigma surrounding ED may prevent individuals from disclosing their condition to dental professionals, further delaying appropriate preventive or therapeutic interventions(Reference Inchingolo, Dipalma and Azzollini61). Therefore, poor oral hygiene should be considered not only because of ED but also as a modifiable co-factor contributing to the progression of ED-related oral pathology.
However, there is an apparent discrepancy between clinical assumptions mentioned and patient-reported behaviours, highlighting the complexity of the relationship between ED and oral hygiene. The existing literature suggests that women with ED often show enhanced oral hygiene practices and attitudes towards dental visits comparable to the general population(Reference Shaughnessy, Feldman and Cleveland36). A survey conducted in 2016 involving thirty patients with ED found that 40 % of patients brushed their teeth more than twice daily, compared with 17·24 % of controls (P = 0·01)(Reference Mazurek, Szyszkowska and Mazurek50). Regarding oral hygiene after the onset of illness, 56·67 % of patients reported an increase in oral care, while 40 % reported no change in their routine(Reference Mazurek, Szyszkowska and Mazurek50). Additionally, when inquired about their oral hygiene habits following the onset of their illness, 56·67 % of patients indicated that they engaged in more diligent oral care(Reference Mazurek, Szyszkowska and Mazurek50).
Several factors may help reconcile this discrepancy. On one hand, self-reported improvements in oral hygiene may reflect compensatory behaviours, particularly among individuals with BN who may attempt to mitigate the perceived effects of vomiting on dental health. On the other hand, the psychological profile of certain individuals with ED, marked by perfectionism and obsessive-compulsive traits(Reference Studen-Pavlovich and Elliott60), may drive more frequent hygiene routines, potentially masking deeper underlying oral pathology. Finally, enhanced frequency of toothbrushing, especially immediately after purging episodes, may paradoxically contribute to dental erosion due to mechanical abrasion of already acid-weakened enamel.
Dental professionals’ role and approach
To effectively address the clinical conditions of the oral cavity in patients with ED, a proactive, comprehensive and personalised approach involving dental practitioners and dental hygienists is indispensable. This strategy emphasises the importance of preventive care, early detection and multidisciplinary collaboration, focusing on the unique oral health challenges faced by this patient population. Defining ‘early-stage’ ED is crucial to optimise timely intervention and improve clinical outcomes. Recent staging models characterise early stages by the emergence of initial symptoms that may not yet fulfil full diagnostic criteria for severe or enduring illness(Reference Treasure, Stein and Maguire62,Reference Tomba, Tecuta and Gardini63) . These stages can be identified through targeted oral health assessments revealing early clinical signs such as enamel erosion, mild gingivitis, xerostomia and nutritional deficiencies. Recognition of these oral manifestations enables dental practitioners to detect ED promptly, facilitating intervention before disease progression and supporting integration within a multidisciplinary treatment framework(Reference Treasure, Stein and Maguire62,Reference Tomba, Tecuta and Gardini63) .
Dental practitioners should prioritise regular monitoring and individualised care plans for patients with ED(Reference Pallier, Karimova and Boillot49). Scheduling periodic recall visits is essential to reducing the incidence of periodontal and dental lesions(Reference Pallier, Karimova and Boillot49). A check-up serves as a cornerstone for this approach, enabling the systematic assessment of critical parameters, including the plaque index, gingival recession, and the BEWE index(Reference Pallier, Karimova and Boillot49). These indicators facilitate the early detection of pathological changes and allow for timely interventions.
The prevention of secondary lesions requires the effective removal of bacterial plaque retention factors, which is particularly significant for patients with systemic conditions associated with ED(Reference Dehghan, Tantbirojn and Harrison30). Salivary dysfunction, a common complication in these patients, diminishes the natural buffering capacity of saliva, increasing oral acidity and heightening the risk of carious lesions. This vulnerability is reflected in elevated scores on the decayed, missing and filled teeth index(Reference Dehghan, Tantbirojn and Harrison30). Dental professionals must address these risk factors through meticulous plaque control and tailored therapeutic interventions(Reference Dehghan, Tantbirojn and Harrison30).
Initial evaluations should focus on determining each patient’s susceptibility to dental erosion, emphasising the assessment of local risk factors such as plaque accumulation(Reference Aránguiz, Lara and Marró64). Preventive measures, including remineralisation therapy and dietary counselling, should be integrated into a broader therapeutic framework. This requires collaboration with dieticians and nutritionists to develop a nutritional therapeutic plan aimed at mitigating the progression of dental erosion. Remineralisation protocols should be individualised based on the patient’s degree of susceptibility, as determined by the BEWE index.
The BEWE index provides a standardised methodology for quantifying dental erosion, categorising enamel loss on a scale from 0 (no enamel loss) to 3 (loss exceeding 50 % of the tooth surface)(Reference Aránguiz, Lara and Marró64); the highest score within each sextant of the dentition is recorded, and the total BEWE score is calculated by summing these values(Reference Aránguiz, Lara and Marró64). Based on the cumulative score, patients are classified into four categories of susceptibility: no susceptibility (0–2), low susceptibility (3–8), medium susceptibility (9–13) and high susceptibility (≥14)(Reference Aránguiz, Lara and Marró64). This classification informs the duration and intensity of remineralisation protocols, which range from two months for low susceptibility to 6 months for high susceptibility(Reference Aránguiz, Lara and Marró64). Biomimetic hydroxyapatite-based substances are recommended for these treatments due to their efficacy in enamel restoration and resistance to further erosion(Reference Aránguiz, Lara and Marró64).
Dental erosion compromises the enamel layer, exposing the underlying dentin and its associated nerve endings, thereby increasing dentin hypersensitivity(Reference Butera, Gallo and Pascadopoli65). To evaluate the success of remineralisation therapy, clinicians should employ the Schiff air index, a diagnostic tool that quantifies patient sensitivity to air stimulation. Scores range from 0 (no response) to 3 (severe pain and withdrawal), providing an objective measure of therapeutic outcomes and patient progress(Reference Butera, Gallo and Pascadopoli65).
Recent advances in teledentistry have expanded the potential for remote patient monitoring and intervention, where using specialised applications, patients can submit self-assessments and images for professional evaluation(Reference Giraudeau, Camman and Pourreyron66). This technology supports the ongoing management of dental, periodontal and nutritional conditions, offering a practical solution for maintaining care continuity between in-person visits(Reference Giraudeau, Camman and Pourreyron66). Such approaches allow dental practitioners to extend their involvement beyond traditional clinical settings, ensuring comprehensive and accessible care for individuals with ED(Reference Giraudeau, Camman and Pourreyron66). Therefore, the integration of these methods underscores the pivotal role of dental professionals in the multidisciplinary management of ED, highlighting the necessity of continuous education, innovative technologies and collaboration to optimise patient outcomes.
Discussion
The findings presented in this narrative review highlight the complex and multifactorial relationship between ED (particularly, AN, BN, BED and OSFED) and oral diseases, with significant implications for patients’ nutritional status and overall health.
Chronic caloric restriction and associated malnutrition, hallmarks of AN and BN, play a central role in the pathophysiology of oral complications(Reference Krug, Fernández-Aranda, Ghahraman Moharrampour, Robinson, Wade, Herpertz-Dahlmann, Fernandez-Aranda, Treasure and Wonderlich67), with widespread micronutrient deficiencies (e.g. Ca, vitamin D, vitamin C and phosphate)(Reference Sanavia and Genovesi55,Reference Botelho, Machado and Proença56) , as well as a lack of protein and healthy fats(Reference Sanavia and Genovesi55,Reference Patterson-Norrie, Ramjan and Sousa68) which can disrupt tooth mineralisation(Reference Butera, Maiorani and Gallo69) and weaken the bones supporting the teeth, increasing the risk of decay and impairing the homeastasis, such as structural integrity and resilience of the oral cavity(Reference Botelho, Machado and Proença56,Reference Patterson-Norrie, Ramjan and Sousa68) . Again, for patients with AN, severe caloric restriction is associated with dry mouth (xerostomia) and gingivitis (primarily due to vitamin C and calcium deficiencies) that weakens the gums and increases infection risk(Reference Johansson, Norring and Unell29,Reference Dehghan, Tantbirojn and Harrison30,Reference Paszynska, Schlueter and Slopien32,Reference Lourenço, Azevedo and Brandão33,Reference Paszyńska, Hernik and Slopien38) . Finally, individuals with AN or BN may experience edentulism (tooth loss), an outcome that, while uncommon, underscores the profound systemic effects these disorders can have, including their impact on oral health(Reference Gidlund, Hasselblad and Larsson-Gran70). The development of edentulism in this context is primarily driven by behaviours and physiological changes associated with disorders that directly or indirectly harm the integrity of teeth and supporting structures(Reference Ashcroft and Milosevic71).
This imbalance often perpetuates disordered eating behaviours, as painful or difficult chewing makes mealtime distressing, leading to avoidance of necessary foods(Reference Patterson-Norrie, Ramjan and Sousa68). The cumulative effects of these oral health complications lead to discomfort, pain and functional limitations, making eating an unpleasant experience and reinforcing disordered eating behaviours(Reference Jayasinghe, Harrass and Erdrich72).
The systemic effects of malnutrition are compounded by purging behaviours (e.g. SIV and laxative or diuretic abuse) related to body image and self-care habits(Reference Panico, Piemonte and Lazos41), thus introducing additional oral stressors, such as acid erosion, salivary dysfunction and increased susceptibility to oral infections(Reference Hasan, Ahmed and Panigrahi25,Reference Dehghan, Tantbirojn and Harrison30,Reference Paszynska, Schlueter and Slopien32) . One of the most significant contributors is gastric acidity, particularly in individuals with BN who engage in SIV(Reference Uhlen, Tveit and Stenhagen31). Repeated contact with gastric contents leads to progressive enamel erosion, weakening the tooth structure, increasing fragility, promoting gingival inflammation, reducing salivary flow and raising the risk of tooth loss(Reference Dynesen, Bardow and Petersson35,Reference Paszyńska, Słopień and Węglarz42,Reference Blazer, Latzer and Nagler44,Reference Manevski, Stojsin and Vukoje48) . These effects are exacerbated by the frequent consumption of sugary and acidic foods, especially among individuals experiencing binge eating episodes, which significantly increase the risk of dental caries(Reference Otsu, Hamura and Ishikawa43). In fact, in BED, the habitual intake of simple carbohydrates and fermentable sugars fosters the proliferation of cariogenic bacteria, thereby heightening the likelihood of both tooth decay and periodontal disease(Reference Johansson, Mjanger Øvretvedt and Reinholtsen34). Similarly, patients diagnosed with OSFED may also exhibit oral manifestations such as dental erosion and gingivitis, particularly in the presence of binge eating or purging behaviours(Reference Panico, Piemonte and Lazos41). Reduced salivary flow exacerbates vulnerability to dental caries and periodontal diseases, further increasing the likelihood of tooth loss(Reference Müller, Chebib and Maniewicz73). Similarly, ED increase the risk of gingival and periodontal diseases, which, exacerbated by poor oral hygiene, nutritional deficiencies and systemic inflammation, can lead to tissue destruction and tooth loss if untreated(Reference Rangé, Colon and Godart74).
An intriguing and paradoxical finding arises from the analysis of oral hygiene behaviours. While clinical assumptions have long suggested a general neglect of oral hygiene in individuals with ED(Reference Hasan, Ahmed and Panigrahi25,Reference Inchingolo, Dipalma and Azzollini61) , some self-reported data(Reference Shaughnessy, Feldman and Cleveland36,Reference Wani, Chakole and Agrawal51,Reference Studen-Pavlovich and Elliott60) contradict this view, particularly among individuals with BN. Enhanced oral hygiene practices may reflect compensatory routines aimed at mitigating the effects of vomiting, or may be influenced by personality traits such as perfectionism or obsessive-compulsiveness. However, these behaviours (especially toothbrushing immediately after purging) may inadvertently accelerate enamel erosion due to mechanical abrasion of acid-weakened surfaces.
Therefore, as oral health declines, the capacity to maintain a balanced diet diminishes, which exacerbates both nutritional imbalances and the physical manifestations of ED(Reference Gidlund, Hasselblad and Larsson-Gran70). Further, deteriorating oral health can affect social interactions and self-esteem, intensifying the psychological burden of ED(Reference Reas and Rø57).
The present review also highlights the critical role of dental practitioners and hygienists in the early identification and multidisciplinary management of ED. Dental professionals are often among the first to observe early manifestations of ED, such as enamel erosion, gingival inflammation or xerostomia(Reference DeBate, Tedesco and Kerschbaum27), and they are uniquely positioned to initiate timely referrals and preventive interventions or supporting recovery efforts(Reference DeBate, Tedesco and Kerschbaum27). The use of clinical indices such as BEWE(Reference Bartlett, Ganss and Lussi75) and Schiff air index(Reference Gillam and Orchardson76), alongside teledentistry tools(Reference Daniel, Wu and Kumar77), can enhance early detection and longitudinal monitoring of oral health status, particularly in vulnerable or hard-to-reach populations.
By addressing oral diseases within the context of ED management, healthcare professionals can alleviate certain physical barriers to nutrition, supporting a comprehensive recovery that encompasses the physiological, nutritional and psychological complexities of ED.
Reduced salivary flow exacerbates vulnerability to dental caries and periodontal diseases, further increasing the likelihood of tooth loss(Reference Müller, Chebib and Maniewicz73). Similarly, ED increase the risk of gingival and periodontal diseases, which, exacerbated by poor oral hygiene, nutritional deficiencies and systemic inflammation, can lead to tissue destruction and tooth loss if untreated(Reference Rangé, Colon and Godart74).
Overall, the findings described in the present narrative review highlight the importance of a multidisciplinary approach that includes oral health in the treatment of ED, aiming to enhance early diagnosis and management of oral complications. However, it is interesting to note that although a growing body of literature examines the impact of ED on oral health, significant gaps remain, particularly regarding diverse demographic representation. Most studies reviewed focus on women and younger individuals, overlooking potential variations in ED-related oral health effects among men and older adults(Reference Dehghan, Tantbirojn and Harrison30,Reference Paszynska, Schlueter and Slopien32,Reference Lourenço, Azevedo and Brandão33,Reference Dynesen, Bardow and Petersson35–Reference Chiba, Sumida and Moimaz37,Reference Chiba, Chiba and Moimaz39–Reference Esteves, Freitas and Campos45,Reference Emodi-Perlman, Yoffe and Rosenberg47,Reference Pallier, Karimova and Boillot49,Reference Mazurek, Szyszkowska and Mazurek50) . Additionally, inconsistent diagnostic criteria(Reference Johansson, Norring and Unell29,Reference Uhlen, Tveit and Stenhagen31,Reference Dynesen, Bardow and Petersson35,Reference Chiba, Sumida and Moimaz37,Reference Chiba, Chiba and Moimaz39,Reference Manevski, Stojsin and Vukoje48,Reference Mazurek, Szyszkowska and Mazurek50) contribute to discrepancies in findings, hindering definitive conclusions. Finally, despite advancements, the high prevalence of ED comorbid with other psychological conditions remains underexplored, potentially leading to the neglect of comprehensive care strategies(Reference Momen, Plana-Ripoll and Yilmaz78). While meta-analyses(Reference Monteleone, Pellegrino and Croatto79) confirm the efficacy of treatments for ED, a substantial group of patients shows inadequate response to existing therapies(Reference Downs, Ayton and Collins80).
Therefore, future research should address these limitations, focusing on understanding and addressing the needs of this overlooked group, thereby improving prevention and treatment strategies tailored to individual needs.
Conclusions
The interplay between ED and oral health is driven by a combination of nutritional, behavioural and psychosocial factors. An integrated care model, encompassing dental, medical, nutritional and psychological expertise, is essential for mitigating oral health risks and improving overall outcomes for individuals with ED.
This review emphasises the critical need for routine dental screenings in at-risk populations, where early detection of oral manifestations, such as enamel erosion, xerostomia and increased caries, may reveal underlying disordered eating behaviours.
Advocating for a collaborative, interdisciplinary model, this review underscores the necessity of integrating dental and psychological care into a more holistic treatment approach. Addressing ED in this manner not only targets primary psychological drivers but also addresses the systemic and often severe physiological repercussions of these disorders, especially in the oral cavity, where effects can be particularly profound. By coordinating nutritional management with dental treatment, healthcare providers can create a cohesive care plan that enhances the efficacy of both psychological and physiological interventions. This integrative model strives to deliver timely and tailored care that enhances patients’ quality of life through early diagnosis and prompt intervention. Additionally, it emphasises the importance of increasing awareness among healthcare professionals, who must recognise the link between oral health deterioration and ED. By fostering a deeper understanding of this connection, healthcare providers are better equipped to identify, support and manage at-risk individuals, contributing to improved patient outcomes and a more comprehensive healthcare framework.
Acknowledgements
Since none of the authors are native English speakers, the present narrative review utilised generative artificial intelligence (e.g. ChatGPT tool) to check for any grammatical errors, enhance the writing style and effectively convey certain observations. Nevertheless, the use of artificial intelligence in the manuscript remained below 10 %.
Conceptualisation, A. C. and R. D. G.; methodology, R. D. G., G. M., F. S.; investigation, A. C., G. M., F. S.; data curation, G. M., F. S.; writing – original draft preparation, G. M., F. S., R. D. G.; writing – review and editing, R. D. G., A. B.; supervision, H. C., A. S. All authors have read and agreed to the published version of the manuscript.
This research received no external funding.
The authors declare no conflicts of interest.
Open access
