Eating disorders

One of the main findings of this study was that the responding dentists had a limited
clinical experience in the management of ED. As ED is not an infrequent condition,
it is in general of importance for dentists to evaluate and reach a better level of
knowledge in this field through education and training.

In a recent Finnish study, lifetime prevalence and current ED diagnosis in young females
and males (aged 20–35 years) were 6 and 2 %, respectively, and it was concluded that
ED was the fourth largest group of mental disorders among young women and that the
dentists’ exposure to ED patients was higher than reported 20]. Since it is clear that many patients with a diagnosis of ED do not inform the dentist
(or anyone else) about their condition, it is likely that dentists relatively frequently
treat dental patients without being aware that they have an ED.

The majority of dentists in our study rated their knowledge regarding ED to be relatively
good to very good. However, the majority had only treated an average of 5 patients
with ED or less during their professional lives. This indicates a generally unsatisfactory
and limited clinical experience of patients with ED, in similarity to previous studies
14], 19]. The female dentists rated their level of knowledge significantly better than the
males and in general the levels were higher than in a similarly-designed Swedish study
19]. The finding of superior self-rated general knowledge about ED among female compared
to male dentists has been reported previously 16]. Female dentists also reported greater difficulty than male dentists in informing
the patient/relatives about their ED suspicions. It is well known that eating disorders
are significantly overrepresented among women. What is not as well known is that cognitions
and attitudes associated with eating disorders, but without the presence of a diagnosable
eating disorder, are very common in women 21]. During adolescence and early adulthood, many women undergo a period characterized
by such thoughts and feelings. Women consequently know more about, but also to a greater
extent identify themselves with, eating disorder problems. This could very well explain
why female dentists find it more difficult to inform patients about a possible eating
disorder 21].

The knowledge of the dentists in the present study was largely obtained from sources
like media or own experience. Dentists with shorter working experience reported significantly
better knowledge compared to those with longer experience. The former had most likely
had teaching of ED included in their undergraduate curriculum and thereby gained more
knowledge from dental school compared to the latter. This finding may reflect positively
on modern dental education, but it has to be remembered that Bulimia Nervosa, as one
of the most common ED diagnoses, was first established in 1979 22] and consequently could not have been included in older dental curricula.

Only about half of the dentists felt that the patient/relative should be informed
in a case of suspected ED. A reluctance by dentists and dental hygienists to convey
such information has been reported earlier 15], 16]. This may result in the chance for early detection of the disease being lost, which
is deemed to be very important for a successful management of ED 9]. In this regard it is important to remember that, among those dentists who informed
the patient/guardian about their suspicion of ED, about half of the patients confirmed
the suspicion when being asked. Among the other half of patients who did not confirm
the ED diagnosis, this information provided by the dentist may well be taken as a
warning sign from a de facto ED patient and hopefully lead her/him to seek treatment later in another setting.

Of the total number of responders, 6 % of female dentists and 0.5 % of males reported
that they had suffered from ED themselves, which roughly corresponds to the estimated
prevalence and gender distribution within the general population (20).

One Swedish survey concluded that a more structured cooperation between the dental
team and other actors involved in the management of ED patients should be implemented
23]. In the present study, relatively few dentists recommended the patient to seek other
medical care or referred them to other health care facilities, similar to that found
in the Swedish study 19]. In Norway, the recommendation for ED patients is to be referred mainly to the general
medical practitioner or a psychologist. As regard dental management of ED patients,
only 4 % of the respondents believed that the dental care system in Norway provided
adequate help. Nevertheless, it seems to be of utmost importance that dentists in
Norway are informed about the available alternatives for management of ED patients.

The majority of dentists were aware of they had treated ED patients during the preceding
year, although the majority of them had only encountered a few patients in their professional
lives. In addition, most of the dentists believed that ED patients had more oral complications
than an ordinary patient. Therefore, it was not an unexpected finding that the majority
reported that they needed more training in the dental management of ED patients. This
supports conclusions from previous studies and suggestions to implement more training
in the management of ED patients in undergraduate, postgraduate as well as in continuing
dental education 19], 23], 24].

The ability to generalize from the results of a questionnaire depends on sufficient
number of responders. A response rate of at least 60 % is set as a minimum requirement
for publication by some scientific journals 25]. However, there is a steady decline in response rates in published surveys of health
care providers in the USA, and during 2005–2008 only about 35 % met the 60 % criteria
and none in 2009 26]. This was also true for postal surveys of healthcare professionals covering 1996
to 2005, where the response rate (350 studies, average response rate 58 %) was significantly
lower than during the previous 10-year period. It was even lower in studies with more
than 1000 participants. The conclusion drawn in 2005 was that response rates to postal
surveys of healthcare professionals were low and probably declining, which may lead
to unknown levels of bias 27]. In line with the forgoing, it was not surprising that we only reached an overall
response rate of 40 % in this study that was performed in 2010 and having a high number
of selected participants (N?=?4282). The reasons for low response rate to questionnaires and strategies to overcome
such problems have been thoroughly elaborated on in a systemic review where 110 different
approaches were assessed with the conclusion drawn that there are many ways to increase
the response rate in questionnaire surveys 28].

If the number of responders is inferior to the number of non-responders, it will be
a weakness in the interpretation of the conclusions. The low response rate in the
present study makes it difficult to draw valid conclusions for the total population
of Norwegian dentists. On the other hand, the questionnaire was sent to all Norwegian
dentists and the responders represent one specific professional occupation. The questionnaire
included specific work related questions and statements, which allow meaningful correlations
and conclusions to be drawn. Because of restrictions set by the Norwegian data protection
authority and ethical committee, the only non-response analysis that could be performed
was related to work affiliation.