DCA06DT Dental Treatment of Pediatric and Adolescent Patients _ __________________________________
Other suggestions for improving reporting include [54]: Improving the relationship between CPS and dental providers • Allowing certain registered professionals with demonstrated expertise in identifying/treating child abuse “flexible reporting options” (e.g., deferring reporting when no immediate threat exists or making the report confidentially and deferring an investigation until deemed necessary) • Improving interaction with the legal system
Self-induced vomiting and use of laxatives can cause a severe disturbance in the body’s mineral and electrolyte balance, and a drastic reduction of the minerals potassium, sodium, and calcium can interfere with the conduction of nerve impulses and the contraction of smooth, skeletal, and cardiac muscle. Failure of multiple organs and systems can lead to death. If part of the disease process, repeated episodes of self-induced vomiting can cause ulceration of the esophageal lining, with the subsequent development of esophageal varicosities and bleeding. Oral effects are generally limited to those caused by extreme starvation and malnutrition. BULIMIA NERVOSA Patients with bulimia nervosa tend to lack the emaciated appearance of patients with anorexia nervosa; their body weight and appearance often appears normal. Bulimia features recurrent binge eating, in which a large quantity of food is con- sumed in a short time, followed by purging (e.g., self-induced vomiting, use of diuretics, laxatives, or enemas) to compensate for the excessive overeating. During binging episodes, the bulimic patient experiences a loss of control over the quantity and variety of food consumed [62]. The practice of binge eat- ing and purging must continue at least twice a week for three months for a diagnosis of bulimia nervosa to be made [61]. The teeth and the oral mucosa of bulimic patients can undergo damage as the recurrent regurgitation of highly acidic gastric contents can induce pathologic change in both. In addition, the mucosa of the soft palate and the anterior pharyngeal area can be traumatized when fingers or objects are inserted to induce vomiting. Healing of these areas may be prolonged by the physical and chemical assault associated with this repeti- tious behavior. Ulcerated areas of the oral mucosa may lead to local or regional oral infections. The virulence of infections can be exacerbated when the altered nutritional status of these patients compromises their immune response. Enamel is the hardest substance in the human body, but the repeated exposure to the hydrochloric acid in regurgitated gastric contents over an extended period of time can lead to a unique pattern of enamel erosion called perimylolysis. Perimy- lolysis features the loss of enamel on the lingual, occlusal, and incisal surfaces of the teeth. As opposed to attrition, which is the loss of enamel from repetitive tooth-to-tooth contact or abrasion via an external source (e.g., excessive or overly forceful tooth brushing), the gradual dissolution of the enamel matrix in patients with bulimia leaves a glossy, smooth surface, most commonly on the lingual surfaces of the maxillary anterior teeth [63]. Any lost enamel cannot be regenerated. The underly- ing matrix of dentin is then exposed; it will wear faster than enamel and is more prone to caries. While enamel is devoid of any neural element, dentin contains dentinal tubules whose odontoblastic processes can perceive thermal stimuli as a source of pain. This can cause patients to neglect oral hygiene
EATING DISORDERS AND DENTAL HEALTH
Few behavioral or psychologic problems have as direct an adverse effect upon the teeth and the oral mucosa as anorexia nervosa and bulimia nervosa. There are classic oral manifesta- tions of these eating disorders that members of the dental staff may discover during the course of routine dental treatment. The exact etiology of eating disorders is unknown, but a com- bination of genetic, hormonal, social, cultural, and attitudinal factors are believed to be involved. Images in mass media that promote a thin body as a vehicle to success and happiness have been implicated in altering a person’s perception of his or her appearance [59]. ANOREXIA NERVOSA Patients with anorexia nervosa have an extreme obsession with their body weight and the restriction of food intake. Women comprise 90% to 95% of anorexia cases, and it is estimated that 1% of all women between 12 and 25 years of age have anorexia, with the onset usually occurring during the adolescent years [60]. Anorexic patients often view themselves as overweight even though most are 15% or more below ideal weight. Patients with anorexia go to extreme measures to lose weight and prevent weight gain. The most common mechanism is restricting or halting eating. Other patients may exercise exces- sively. Some patients with anorexia will use laxatives, enemas, or self-induced vomiting as a supplemental means to control their weight. These behaviors can lead to severe acute and chronic medical problems. Patients may appear emaciated but refuse to acknowledge the serious nature of the problem and do not consider the potential medical consequences of the disease. Women who are anorexic often have irregular menstrual cycles. The skin can become dry and thin and at greater risk for traumatic injury. The restriction of caloric intake can stunt the physical and mental development of children and adolescents, and cognitive damage is possible in all patients. Problems with the cardiovascular system, including hypoten- sion, bradycardia, and cardiac arrhythmias, are very common.
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