Eating Disorders and Patient Management Strategies

Eating disorders (ED), more recently denoted as Feeding and Eating Disorders by the American Psychiatric Association (APA) and World Health Organization, are prevalent conditions worldwide.1American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, Va: American Psychiatric Association; 2013:338-350.^,2World Health Organization. International Statistical Classification of Diseases and Related Health Problems, 11th Revision (ICD‐11). Geneva:World Health Organization; 2019.^,3Galmiche M, Déchelotte P, Lambert G, Tavolacci MP. Prevalence of eating disorders over the 2000-2018 period: a systematic literature review. Am J Clin Nutr 2019;109(5):1402-1413. doi: 10.1093/ajcn/nqy342. Based on a systematic review, the prevalence of ED increased to 7.8% between 2013 and 2017, from 3.5% for 2000 to 2006.3Galmiche M, Déchelotte P, Lambert G, Tavolacci MP. Prevalence of eating disorders over the 2000-2018 period: a systematic literature review. Am J Clin Nutr 2019;109(5):1402-1413. doi: 10.1093/ajcn/nqy342. In the US, it is estimated that 28.8 million individuals will suffer from ED during their lifetime.4Deloitte Access Economics. The Social and Economic Cost of Eating Disorders in the United States of America: A Report for the Strategic Training Initiative for the Prevention of Eating Disorders and the Academy for Eating Disorders. June 2020. https://www.hsph.harvard.edu/striped/report-economic-costs-of-eating-disorders/. In addition, these disorders are more prevalent in females, typically first appearing in younger individuals.5National Institute of Mental Health. Eating Disorders. https://www.nimh.nih.gov/health/topics/eating-disorders. ED includes anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder, and avoidant/restrictive food intake disorder.5National Institute of Mental Health. Eating Disorders. https://www.nimh.nih.gov/health/topics/eating-disorders.^,6Hay P. Current approach to eating disorders: a clinical update. Intern Med J 2020;50(1):24-29. doi:10.1111/imj.14691. In this article, we will discuss AN and BN, their impact on oral and systemic health, and the role of dental professionals.

Characteristics of AN and BN

Individuals with AN range from being underweight with a body mass index (BMI) of <18 kg/m² to extremely thin.1American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, Va: American Psychiatric Association; 2013:338-350. This syndrome includes individuals who severely reduce their caloric intake and individuals engaging in both caloric reduction and binging-purging. Affected individuals may also exercise excessively in order to control weight and may/may not have an intense fear of becoming fat.1American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, Va: American Psychiatric Association; 2013:338-350.^,7Lo Russo L, Campisi G, Di Fede O, et al. Oral manifestations of eating disorders: a critical review. Oral Dis 2008;14(6):479-484. Individuals with BN are of normal weight or overweight and indulge in uncontrolled binge-eating followed by purging achieved by vomiting, use of strong laxatives, exercise, enemas or diuretics.5National Institute of Mental Health. Eating Disorders. https://www.nimh.nih.gov/health/topics/eating-disorders. In accordance with the APA diagnostic criteria for BN, binge-eating and purging must occur at least once a week for a minimum of 3 months.1American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, Va: American Psychiatric Association; 2013:338-350. There is overlap in the behaviors of individuals with AN and BN. More than half of individuals with AN also engage in bulimic behavior with self-induced vomiting (SIV), and atypical BN with binge-eating and severe caloric restriction and/or aggressive exercise regimens also exists.6Hay P. Current approach to eating disorders: a clinical update. Intern Med J 2020;50(1):24-29. doi:10.1111/imj.14691.^,8Milosevic A. Eating disorders and the dentist. Br Dent J 1999;186:109-113. https://doi.org/10.1038/sj.bdj.4800036. In both AN and BN, the patient has a distorted view of their body image. (Figure 1)

Risk Factors

Risk factors for ED include genetic, environmental and psychological factors.9Bulik CM, Blake L, Austin J. Genetics of Eating Disorders: What the Clinician Needs to Know. Psychiatr Clin North Am 2019;42(1):59-73. doi: 10.1016/j.psc.2018.10.007.^,10Gaudio S, Quattrocchi CC. Neural basis of a multidimensional model of body image distortion in anorexia nervosa. Neurosci Biobehav Rev 2012;36(8):1839-1847. doi: 10.1016/j.neubiorev.2012.05.003. Genetic factors include a neural predisposition, and predispositions for perfectionism, anxiety, weight gain and associated obsessive dieting.7Lo Russo L, Campisi G, Di Fede O, et al. Oral manifestations of eating disorders: a critical review. Oral Dis 2008;14(6):479-484.^,10Gaudio S, Quattrocchi CC. Neural basis of a multidimensional model of body image distortion in anorexia nervosa. Neurosci Biobehav Rev 2012;36(8):1839-1847. doi: 10.1016/j.neubiorev.2012.05.003.^,11Lulé D, Schulze UME, Bauer K, et al. Anorexia nervosa and its relation to depression, anxiety, alexithymia and emotional processing deficits. Eat Weight Disord 2014;19:209-216. Studies in identical twins and more recently genome-wide research have confirmed the role of genetics.8Milosevic A. Eating disorders and the dentist. Br Dent J 1999;186:109-113. https://doi.org/10.1038/sj.bdj.4800036.^,9Bulik CM, Blake L, Austin J. Genetics of Eating Disorders: What the Clinician Needs to Know. Psychiatr Clin North Am 2019;42(1):59-73. doi: 10.1016/j.psc.2018.10.007. BN is considered to have a heritability of 0.60.9Bulik CM, Blake L, Austin J. Genetics of Eating Disorders: What the Clinician Needs to Know. Psychiatr Clin North Am 2019;42(1):59-73. doi: 10.1016/j.psc.2018.10.007. Gender is also a risk factor, with an 11-fold risk of AN for females if they have relatives with this condition. Environmental factors include cultural / societal pressures to be thin, especially for adolescent and young adult females.8Milosevic A. Eating disorders and the dentist. Br Dent J 1999;186:109-113. https://doi.org/10.1038/sj.bdj.4800036.^,12Westmoreland P, Krantz MJ, Mehler PS. Medical Complications of Anorexia Nervosa and Bulimia. Am J Med 2016;129(1):30-37. doi: 10.1016/j.amjmed.2015.06.031. Familial factors include a history of depression, obsessive-compulsive disorder (OCD) and alcohol abuse.9Bulik CM, Blake L, Austin J. Genetics of Eating Disorders: What the Clinician Needs to Know. Psychiatr Clin North Am 2019;42(1):59-73. doi: 10.1016/j.psc.2018.10.007. Traumatic events such as childhood abuse, neglect and bullying are also risk factors.8Milosevic A. Eating disorders and the dentist. Br Dent J 1999;186:109-113. https://doi.org/10.1038/sj.bdj.4800036. In addition, weight control creates an occupational risk factor for models, ballerinas, ice skaters, gymnasts and other athletes where lean body mass is preferred.13Mancine RP, Gusfa DW, Moshrefi A, et al. Prevalence of disordered eating in athletes categorized by emphasis on leanness and activity type – a systematic review. J Eat Disord 2020;8:47. https://doi.org/10.1186/s40337-020-00323-2. (Figure 2)

Systemic Health Impact

Severe morbidity and mortality can occur with AN and BN. At extremely low weights, patients suffer from cardiovascular disease, metabolic and endocrine dysfunction. Among individuals with severe AN and malnutrition, BMI may be very low and, at a lifetime average of 10.5kg/m², 45% of individuals will die prematurely.14Gaudiani JL, Braverman JM, Mascolo M, Mehler PS. Ophthalmic changes in severe anorexia nervosa: a case series. Int J Eat Disord 2012;45(5):719-721. doi: 10.1002/eat.20970. Individuals with BN also experience higher mortality rates than the general population.15Crow SJ, Peterson CB, Swanson SA, et al. Increased mortality in bulimia nervosa and other eating disorders. Am J Psychiatry 2009;166:1342-1346. Furthermore, attempted suicide is reported in approximately 1 in 4 individuals with ED. AN is associated with gastrointestinal disorders including dysphagia, slowed gastric emptying, nausea, bloating and potential for gastric perforation.16Lin JA, Woods ER, Bern EM. Common and Emergent Oral and Gastrointestinal Manifestations of Eating Disorders. Gastroenterol Hepatol (NY) 2021;17(4):157-167. Other conditions include fatty liver, cardiovascular disease, renal disease, anemia, leukopenia, thrombocytopenia, a suppressed immune system, amenorrhea with subsequent osteopenia/osteoporosis, thyroid abnormalities, risk for infertility, multi-organ failure and brain damage.5National Institute of Mental Health. Eating Disorders. https://www.nimh.nih.gov/health/topics/eating-disorders.^,7Lo Russo L, Campisi G, Di Fede O, et al. Oral manifestations of eating disorders: a critical review. Oral Dis 2008;14(6):479-484.^,12Westmoreland P, Krantz MJ, Mehler PS. Medical Complications of Anorexia Nervosa and Bulimia. Am J Med 2016;129(1):30-37. doi: 10.1016/j.amjmed.2015.06.031. In addition, individuals experience thinning of hair while displaying fine pigmented hair on their body and face known as lanugo, severe acne, brittle nails, dry and yellowish skin, or may have cyanotic bluish skin. Hypertension, ulcers, diabetes, constipation, anxiety, depression, and other physical and mental illness occur in patients with AN or BN, and quality-of-life is severely impacted.16Lin JA, Woods ER, Bern EM. Common and Emergent Oral and Gastrointestinal Manifestations of Eating Disorders. Gastroenterol Hepatol (NY) 2021;17(4):157-167.^,17Ágh T, Kovács G, Supina D, et al. A systematic review of the health-related quality of life and economic burdens of anorexia nervosa, bulimia nervosa, and binge eating disorder. Eat Weight Disord 2016;21(3):353-364. doi:10.1007/s40519-016-0264-x.18. (Table 1)

^a Effects of bulimic behavior are contained in Table 2

Individuals with BN or bulimic behavior have severe electrolyte disturbances. SIV is achieved by placing fingers or an object down the throat or by using ipecac syrup, a cumulative toxin causing cardiovascular complications.18Mickley D, Greenfeld D, Quinlan DM, et al. Abnormal liver enzymes in outpatients with eating disorders. Int J Eat Disord 1996;20(3):325-329. Repeated vomiting results in ongoing acid reflux, dysphagia, dyspepsia (indigestion), laryngeal damage, hoarseness, hematemesis, potential for esophageal rupture/malignancy, pancreatitis, metabolic alkalosis and hypokalemia which in severe cases cause cardiac arrythmias, epistaxis (bleeding from the nose), subconjunctival hemorrhages and sialadenitis.12Westmoreland P, Krantz MJ, Mehler PS. Medical Complications of Anorexia Nervosa and Bulimia. Am J Med 2016;129(1):30-37. doi: 10.1016/j.amjmed.2015.06.031.^,15Crow SJ, Peterson CB, Swanson SA, et al. Increased mortality in bulimia nervosa and other eating disorders. Am J Psychiatry 2009;166:1342-1346.^,17Ágh T, Kovács G, Supina D, et al. A systematic review of the health-related quality of life and economic burdens of anorexia nervosa, bulimia nervosa, and binge eating disorder. Eat Weight Disord 2016;21(3):353-364. doi:10.1007/s40519-016-0264-x.18. (Table 2) Extended use of laxatives causes lower intestinal tract complications. In addition to physical manifestations, individuals with AN and BN are at risk for substance abuse, promiscuity, and committing theft.1American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, Va: American Psychiatric Association; 2013:338-350.

Oral Manifestations

Oral manifestations involving peri-oral and intra-oral tissues are present in patients with AN and BN.7Lo Russo L, Campisi G, Di Fede O, et al. Oral manifestations of eating disorders: a critical review. Oral Dis 2008;14(6):479-484.^,19Monda M, Costacurta M, Maffei L, Docimo R. Oral manifestations of eating disorders in adolescent patients. A review. Eur J Paediatr Dent 2021;22(2):155-158. doi: 10.23804/ejpd.2021.22.02.13.^,20De Bate R, Tedesco LA, Kerschbaum WE. Knowledge of Oral and Physical Manifestations of Anorexia and Bulimia Nervosa Among Dentists and Dental Hygienists. J Dent Ed 2005;69(3):346-354.^,21Lourenço M, Azevedo Á, Brandão I, Gomes PS. Orofacial manifestations in outpatients with anorexia nervosa and bulimia nervosa focusing on the vomiting behavior. Clin Oral Investig 2018;22(5):1915-1922. doi: 10.1007/s00784-017-2284-y.^,22National Eating Disorders Association. Dental complications of eating disorders. nationaleatingdisorders.org/dental-complications-eating-disorders.^,23Panico R, Piemonte E, Lazos J, et al. Oral mucosal lesions in anorexia nervosa, bulimia nervosa and EDNOS. J Psychiatr Res 2018;96:178-182.^,24Garrido-Martínez P, Domínguez-Gordillo A, Cerero-Lapiedra R, et al. Oral and dental health status in patients with eating disorders in Madrid, Spain. Med Oral Patol Oral Cir Bucal 2019;24(5):e595-e602. Depending on the manifestation, SIV, oral pH changes, nutritional deficiencies, and other factors play a role.

Dental hard tissues
Dental erosion occurs with AN and BN. Based on a recent systematic review, individuals with ED have a five-fold risk for dental erosion compared to the general population.25Kisely S, Baghaie H, Lalloo R, Johnson NW. Association between poor oral health and eating disorders: systematic review and meta-analysis. Br J Psychiatry 2015;207(4):299-305. Exposure to gastric acid as a result of SIV causes erosion of the palatal surfaces of the maxillary anterior teeth, referred to as perimolysis.25Kisely S, Baghaie H, Lalloo R, Johnson NW. Association between poor oral health and eating disorders: systematic review and meta-analysis. Br J Psychiatry 2015;207(4):299-305. (Figure 3) This condition results in a smooth, glassy surface, loss of tooth structure, and notches along anterior incisal edges as erosion progresses. With long-duration SIV, other surfaces also become affected, with loss of vertical dimension. Among individuals with SIV, almost 70% experience dental erosion.26Uhlen MM, Tveit AB, Stenhagen KR, Mulic A. Self-induced vomiting and dental erosion—a clinical study. BMC Oral Health 2014;29:14:92. Extrinsic acids from foods and drinks, such as citrus fruits, pickles, and diet sodas, also contribute to erosion. Erosive wear reduces the depth of enamel and eventually dentin, resulting in restorations and sealants appearing to be raised.20De Bate R, Tedesco LA, Kerschbaum WE. Knowledge of Oral and Physical Manifestations of Anorexia and Bulimia Nervosa Among Dentists and Dental Hygienists. J Dent Ed 2005;69(3):346-354. Once dentin is exposed, patients may also experience dentin hypersensitivity if the dentinal tubules are open.27Liu XX, Tenenbaum HC, Wilder RS, et al. Pathogenesis, diagnosis and management of dentin hypersensitivity: an evidence-based overview for dental practitioners. BMC Oral Health 2020;20:220. https://doi.org/10.1186/s12903-020-01199-z. Furthermore, a low pH removes the smear layer over dentin, increasing the likelihood of open dentinal tubules.

The findings on increased risk for dental caries in patients with ED are equivocal.19Monda M, Costacurta M, Maffei L, Docimo R. Oral manifestations of eating disorders in adolescent patients. A review. Eur J Paediatr Dent 2021;22(2):155-158. doi: 10.23804/ejpd.2021.22.02.13. Some studies but not others support increases in dental caries, with contributory factors noted to be increases to intake of sugars, changes in salivary flow and poor oral hygiene, hyposalivation associated with vomiting/laxative abuse/use of diuretics and dehydration, and some medications prescribed during treatment for AN and BN.19Monda M, Costacurta M, Maffei L, Docimo R. Oral manifestations of eating disorders in adolescent patients. A review. Eur J Paediatr Dent 2021;22(2):155-158. doi: 10.23804/ejpd.2021.22.02.13. Dehydration and hyposalivation are well-recognized as risk factors for dental erosion, dental caries, several oral mucosal manifestations and halitosis.

Sialadenitis
Sialadenitis (parotid gland enlargement) is a frequent bilateral manifestation in individuals with SIV.

Oral mucosal and peri-oral manifestations
Oral mucosal manifestations are common with AN and BN, including angular cheilitis, atrophic glossitis, labial erythema, oral candidiasis, oral ulcerations and mucositis, gingival bleeding, dry cracked lips, glossodynia (burning tongue), check/lip biting, a yellowish orange discoloration of the soft palate associated with overconsumption of carotenoids, and mucosal trauma.19Monda M, Costacurta M, Maffei L, Docimo R. Oral manifestations of eating disorders in adolescent patients. A review. Eur J Paediatr Dent 2021;22(2):155-158. doi: 10.23804/ejpd.2021.22.02.13.^,24Garrido-Martínez P, Domínguez-Gordillo A, Cerero-Lapiedra R, et al. Oral and dental health status in patients with eating disorders in Madrid, Spain. Med Oral Patol Oral Cir Bucal 2019;24(5):e595-e602. SIV is associated with oral ulcerations, oral mucositis, angular cheilitis, labial erythema, and a factor in oral candidiasis.19Monda M, Costacurta M, Maffei L, Docimo R. Oral manifestations of eating disorders in adolescent patients. A review. Eur J Paediatr Dent 2021;22(2):155-158. doi: 10.23804/ejpd.2021.22.02.13.^,21Lourenço M, Azevedo Á, Brandão I, Gomes PS. Orofacial manifestations in outpatients with anorexia nervosa and bulimia nervosa focusing on the vomiting behavior. Clin Oral Investig 2018;22(5):1915-1922. doi: 10.1007/s00784-017-2284-y.^,23Panico R, Piemonte E, Lazos J, et al. Oral mucosal lesions in anorexia nervosa, bulimia nervosa and EDNOS. J Psychiatr Res 2018;96:178-182.^,24Garrido-Martínez P, Domínguez-Gordillo A, Cerero-Lapiedra R, et al. Oral and dental health status in patients with eating disorders in Madrid, Spain. Med Oral Patol Oral Cir Bucal 2019;24(5):e595-e602. Mucosal trauma of the palate, as well as the pharynx and posterior tongue, results from fingers or inanimate objects introduced intraorally for SIV. Nutritional deficiencies are associated with oral candidiasis; atrophic glossitis, glossodynia (vitamin B deficiencies); oral ulcerations (Vit B, folate, and iron deficiencies).7Lo Russo L, Campisi G, Di Fede O, et al. Oral manifestations of eating disorders: a critical review. Oral Dis 2008;14(6):479-484.^,28Lamey PJ, Lamb AB. Prospective study of aetiological factors in burning mouth syndrome. Br Med J (Clin Res Ed) 1988:296:1243-1246.^,29Frydrych AM, Davies GR, McDermott BM. Eating disorders and oral health: a review of the literature. Aust Dental J 2005;50(1):6-15. In addition, lip and cheek biting are found, associated with psychological and emotional disturbance. With respect to periodontal disease, the findings of studies are equivocal.19Monda M, Costacurta M, Maffei L, Docimo R. Oral manifestations of eating disorders in adolescent patients. A review. Eur J Paediatr Dent 2021;22(2):155-158. doi: 10.23804/ejpd.2021.22.02.13.^,20De Bate R, Tedesco LA, Kerschbaum WE. Knowledge of Oral and Physical Manifestations of Anorexia and Bulimia Nervosa Among Dentists and Dental Hygienists. J Dent Ed 2005;69(3):346-354. There is considerable variation for findings on the adequacy of oral hygiene and the influence of nutritional deficiency and host defense mechanisms. However, psychological distress can reduce interest in performing hygiene and oral hygiene, and nutritional deficiencies and resulting blood disorders predispose individuals for periodontal disease.

Role of Dental Professionals and Interprofessional Collaboration

Dental professionals have an opportunity to identify individuals with AN or BN, and to refer them at an early stage for diagnosis and treatment, since most patients more frequently visit the dental office than they do medical facilities. In 2016, it was reported in Ontario that around 25% of patients with bulimia were first identified during an oral health examination.30College of Dental Hygienists of Ontario. Eating Disorders, August 2016. https://www.cdho.org/Advisories/CDHO_Factsheet_Eating_Disorders.pdf. Early identification is particularly important since early intervention is most effective.31Mirror Mirror. Eating Disorder Statistics. Statistics on Eating Disorders Recovery. https://mirror-mirror.org/facts-staticstics. Additionally, one-fifth of individuals with AN will succumb to associated complications without treatment, while treatment results in a complete recovery in 60% of treated individuals. Patients can be screened and examined for oral manifestations and symptoms associated with AN and BN during routine dental visits. Screening involves a review of the medical history form and patients can be asked to complete a questionnaire. The SCOFF questionnaire is quick to complete, with a positive response to at least 2 questions indicating ED is likely.32Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: a new screening tool for eating disorders. West J Med 2000;172(3):164-165. doi:10.1136/ewjm.172.3.164. (Table 4) This questionnaire was tested in more than 200 individuals once developed and found to be 100% sensitive in identifying all patients who had ED (n=116), including for bulimic, anorexic, binging and restrictive disorders.32Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: a new screening tool for eating disorders. West J Med 2000;172(3):164-165. doi:10.1136/ewjm.172.3.164.

In addition to oral manifestations, thinning hair and lanugo are obvious provided they are known to be manifestations. Patients typically place their hands on the arms of the dental chair or on their laps. This provides an opportunity to easily observe whether the patient has Russell’s sign. i.e., calluses on the knuckles or back of the hand usually caused by the act of SIV.33Strumia R. Dermatologic signs in patients with eating disorders. Am J Clin Dermatol 2005;6(3):165-173. doi: 10.2165/00128071-200506030-00003. (Figure 4) In some cases, patients may visit for treatment of an associated condition, such as severe dental erosion or dentin hypersensitivity, again providing an opportunity to identify a patient with ED. It is important when having a conversation with patients about potential ED to be diplomatic, empathetic, and nonjudgmental.

While a review of treatment of ED is beyond the scope of this article, the cornerstone is psycho‐behavioral therapy, typically in an ambulatory care setting unless severe, and help from a multi-disciplinary healthcare team.6Hay P. Current approach to eating disorders: a clinical update. Intern Med J 2020;50(1):24-29. doi:10.1111/imj.14691. It has also been suggested that genetic counselling be a component of treatment.9Bulik CM, Blake L, Austin J. Genetics of Eating Disorders: What the Clinician Needs to Know. Psychiatr Clin North Am 2019;42(1):59-73. doi: 10.1016/j.psc.2018.10.007. Other treatment, depending on comorbidities, may include medications, e.g., anti-depressants or anxiolytics, which include dry mouth as a side effect, increasing risk for dental caries and dental erosion.

Beyond identification of individuals with ED, dental professionals provide preventive care and treatment for individuals with ED. Information and advice can be given to patients about dietary acids, information on dental erosion, and the risk to their oral and systemic health. Preventive care including in-office and prescription-level fluorides can be provided to reduce the risk of dental erosion and dental caries along with oral hygiene instructions, and recommendations to manage and prevent oral mucosal lesions. In patients with advanced erosive wear, restorative care will subsequently be required.

Conclusions

AN and BN have increased in prevalence, with a preponderance of females affected. Risk factors are well-recognized, and genetics plays a significant role for both disorders. Dental professionals are in an ideal position to identify individuals suspected of having AN or BN, and to provide timely referrals. In addition, dental professionals provide treatment related to oral manifestations, as well as providing patients with guidance and advice. Interprofessional collaboration increases the likelihood of early intervention which is associated with a higher success rate for treatment.

References

• 1.American Association of Pediatric Dentistry. Policy on Early Childhood Caries (ECC): Classifications, Consequences, and Preventive Strategies. 2016. https://www.aapd.org/media/policies_guidelines/p_eccclassifications.pdf.
• 2.Fleming E, Afful J. Prevalence of Total and Untreated Dental Caries Among Youth: United States, 2015-2016. NCHS Data Brief 2018;(307):1-8.
• 3.Chen J, Duangthip D, Gao SS et al. Oral Health Policies to Tackle the Burden of Early Childhood Caries: A Review of 14 Countries/Regions. Front Oral Health 2021;2:670154. doi: 10.3389/froh.2021.670154.
• 4.Zhang M, Zhang X, Zhang Y et al. Assessment of risk factors for early childhood caries at different ages in Shandong, China and reflections on oral health education: a cross-sectional study. BMC Oral Health 2020;20(1):139. doi: 10.1186/s12903-020-01104-8.
• 5.Srisilapanan P, Nirunsittirat A, Roseman J. Trends over Time in Dental Caries status in Urban and Rural Thai Children. J Clin Exp Dent 2017;9(10):e1201-06. doi: 10.4317/jced.54054.
• 6.Castillo JL, Palma C, Cabrera-Matta A. Early Childhood Caries in Peru. Front Public Health. 2019;7:337. https://doi.org/10.3389/fpubh.2019.00337.
• 7.Gao XL, Hsu CY, Loh T et al. Dental caries prevalence and distribution among preschoolers in Singapore. Community Dent Health 2009;26(1):12-7.
• 8.Pierce A, Singh S, Lee J et al. The Burden of Early Childhood Caries in Canadian Children and Associated Risk Factors. Front Public Health 2019;7:328. doi: 10.3389/fpubh.2019.00328.
• 9.Petersen PE, Bourgeois D, Ogawa H et al. The global burden of oral diseases and risks to oral health. Bull World Health Org 2005;83(9):661-9.
• 10.Alkhtib AO, Mohamed HG. Current knowledge about early childhood caries in the gulf cooperation council with worldwide reflection: Scoping review of the scientific literature (2010–2021). PLOS Glob Public Health 2023;3(1): e0001228. https://doi.org/10.1371/journal.pgph.0001228.
• 11.Tinanoff N, Baez RJ, Diaz Guillory C et al. Early childhood caries epidemiology, aetiology, risk assessment, societal burden, management, education, and policy: global perspective. Int J Paediatr Dent 2019;29:238-48.
• 12.Meyer F, Enax J. Early Childhood Caries: Epidemiology, Aetiology, and Prevention. Int J Dent 2018:1415873. doi: 10.1155/2018/1415873.
• 13.Abanto J, Carvalho TS, Mendes FM et al. Impact of oral diseases and disorders on oral health-related quality of life of preschool children. Commun Dent Oral Epidemiol 2011;39(2):105-14.
• 14.Shokravi M, Khani-Varzgan F, Asghari-Jafarabadi M et al. The Impact of Child Dental Caries and the Associated Factors on Child and Family Quality of Life. Int J Dent 2023;2023:4335796. doi: 10.1155/2023/4335796.
• 15.Díaz S, Mondol M, Peñate A et al. Parental perceptions of impact of oral disorders on Colombian preschoolers’ oral health-related quality of life. Acta Odontol Latinoam 2018;31(1):23-31.
• 16.Corrêa-Faria P, Silva KC, Costa LR. Impact of dental caries on oral health-related quality of life in children with dental behavior management problems. Braz Oral Res 2022;36:e041. doi: 10.1590/1807-3107bor-2022.vol36.0041.
• 17.Barbosa TDS, Gavião MBD. Evaluation of the family impact scale for use in Brazil. J Appl Oral Sci 2009;17(5):397-403.
• 18.Pakkhesald M, Riyahi E, Alhosseini AAN, Amdjadi P. Impact of dental caries on oral health related quality of life among preschool children: perceptions of parents. BMC Oral Health 2021;21:68. https://doi.org/10.1186/s12903-021-01396-4.
• 19.Scarpelli AC, Oliveira BH, Tesch FC et al. Psychometric properties of the Brazilian version of the early childhood oral health impact scale (B-ECOHIS). BMC Oral Health 2011;11(1):19.
• 20.Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st century—the approach of the WHO Global Oral Health Programme. Commun Dent Oral Epidemiol 2003;31:3-24.
• 21.American Academy of Pediatric Dentistry. Policy. The State of Little Teeth. https://www.aapd.org/assets/1/7/State_of_Little_Teeth_Final.pdf.
• 22.BaniHani A, Deery C, Toumba J et al. The impact of dental caries and its treatment by conventional or biological approaches on the oral health-related quality of life of children and carers. Int J Paediatr Dent 2018;28(2):266-76. doi: 10.1111/ipd.12350.
• 23.Alkarimi H A, Watt R G, Pikhart H et al. Impact of treating dental caries on schoolchildren’s anthropometric dental, satisfaction and appetite outcomes: a randomized clinical trial. BMC Public Health 2012;12:706-14.
• 24.Chrisopoulos S, Harford JE. Oral Health and Dental Care in Australia: Key Facts and Figures 2015, Australian Institute of Health and Welfare and the University of Adelaide, Canberra, ACT, Australia, 2016.
• 25.Ramos-Gomez FJ, Weintraub JA, Gansky SA et al. Bacterial, behavioral and environmental factors associated with early childhood caries. J Clin Pediatr Dent 2002;26(2):165-73. doi: 10.17796/jcpd.26.2.t6601j3618675326.
• 26.Kawashita Y, Kitamura M, Saito T. Early childhood caries. Int J Dent 2011;2011:725320. doi: 10.1155/2011/725320.
• 27.Martínez AR, Ruiz-Guillén A, Romero-Maroto M et al. Impact of Breastfeeding and Cosleeping on Early Childhood Caries: A Cross-Sectional Study. J Clin Med 2021;10:1561. https://doi.org/10.3390/jcm10081561.
• 28.Alade M, Folayan MO, El Tantawi M et al. Early childhood caries: Are maternal psychosocial factors, decision-making ability, and caries status risk indicators for children in a sub-urban Nigerian population? BMC Oral Health 2021;21:73. https://doi.org/10.1186/s12903-020-01324-y.
• 29.Avila WM, Pordeus IA, Paiva SM, Martins CC. Breast and Bottle Feeding as Risk Factors for Dental Caries: A Systematic Review and MetaAnalysis. PLoS ONE 2015;10(11): e0142922. doi:10.1371/journal.pone.0142922.
• 30.Peres KG, Nascimento GG, Peres MA et al. Impact of prolonged breastfeeding on dental caries: A population-based birth cohort study. Pediatrics 2017;140:e20162943.
• 31.Perera PJ, Fernando MP, Warnakulasooriya TD, Ranathunga N. Effect of feeding practices on dental caries among preschool children: a hospital based analytical cross sectional study. Asia Pac J Clin Nutr 2014;23(2):272-7. doi: 10.6133/apjcn.2014.23.2.13.
• 32.Iida H, Auinger P, Billings RJ, Weitzman M. Association between infant breastfeeding and early childhood caries in the United States. Pediatrics 2007;120: e944-52.
• 33.Nirunsittirat A, Pitiphat W, McKinney CM et al. Breastfeeding Duration and Childhood Caries: A Cohort Study. Caries Res 2016;50(5):498-507. https://doi.org/10.1159/000448145.
• 34.Lapps Wert KM, Lindemeyer R, Spatz DL. Breastfeeding, co-sleeping and dental health advice. MCN Am J Matern Child Nurs 2015;40:174-9.
• 35.Clark MB, Slayton RL, AAP Section on Oral Health. Fluoride Use in Caries Prevention in the Primary Care Setting. Pediatrics 2020;146(6):e2020034637.
• 36.Public Health England. Guidance Breastfeeding and dental health. Updated 30 January 2019. https://www.gov.uk/government/publications/breastfeeding-and-dental-health/breastfeeding-and-dental-health.
• 37.Guidance. Delivering better oral health: an evidence-based toolkit for prevention. https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention.
• 38.Lee JY, Bouwens TJ, Savage MF, Vann WF Jr. Examining the cost effectiveness of early dental visits. Pediatr Dent 2006;28(2):102-5, discussion 192-8.
• 39.U.S. Public Health Service Recommendation for Fluoride Concentration in Drinking Water for the Prevention of Dental Caries. Public Health Rep 2015;130(4):318-31.
• 40.American Association of Pediatric Dentistry. Caries-risk Assessment and Management for Infants, Children, and Adolescents. Latest revision, 2019. https://www.aapd.org/media/Policies_Guidelines/BP_CariesRiskAssessment.pdf.
• 41.Weyant RJ, Tracy SL, Anselmo T et al. Topical fluoride for caries prevention: Executive summary of the updated clinical recommendations and supporting systematic review. J Am Dent Assoc 2013;144(11):1279-91. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4581720/.
• 42.American Association of Pediatric Dentistry. Fluoride therapy, revised 2023. https://www.aapd.org/globalassets/media/policies_guidelines/bp_fluoridetherapy.pdf
• 43.American Association of Pediatric Dentistry. Oral Health Policies & Recommendations (The Reference Manual of Pediatric Dentistry). Use of Pit-and-Fissure Sealants (2016). https://www.aapd.org/research/oral-health-policies–recommendations/pit_and_fissure_sealants/.
• 44.Ferreira Zandona AG, Ritter AV, Eidson RS. Dental caries: Etiology, caries risk assessment, and management. Ch2, p43. In: Ritter AV, Boushell LW, Walter R. Sturdevant’s art & science of operative dentistry-e-book. 7th Ed. Elsevier Health Sciences, 2017.
• 45.Slayton RL, Urquhart O, Araujo MWB et al. Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions: A report from the American Dental Association. J Am Dent Assoc 2018;149(10):837-49. e19. doi: 10.1016/j.adaj.2018.07.002. https://www.aapd.org/media/Policies_Guidelines/R_ChairsideGuide.pdf.
• 46.American Academy of Pediatric Dentistry. Policy on the use of silver diamine fluoride for pediatric dental patients. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2022:72-5. https://www.aapd.org/media/Policies_Guidelines/P_SilverDiamine.pdf.
• 47.American Association of Pediatric Dentistry. Guideline on Restorative Dentistry, 2016. https://www.aapd.org/assets/1/7/G_Restorative1.PDF.
• 48.Krol DM, Whelan K, AAP Section on Oral Health. Maintaining and Improving the Oral Health of Young Children. Pediatrics 2023;151(1):e2022060417.
• 49.American Academy of Pediatrics. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. www.aap.org/en-us/Documents/ oralhealth_RiskAssessmentTool.pdf.
• 50.Moyer VA, US Prevention Services Task Force. Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement. Pediatrics 2014;133(6):1102-11.
• 51.Macpherson LM, Rodgers J, Conway DI. Childsmile after 10 years part 2: programme development, implementation and evaluation. Dental Update 2019; 46(3):238-46.