The most important finding in this study is that, even after years of remission, poor oral health persists as a constant reminder of the ED. The tooth damage functioned as a visible, lingering scar that persisted after remission of the ED; this was the overarching theme identified in the data. The three major themes were (1) the physical impact on oral health, (2) the psychological impact of poor oral health, and (3) the impact on daily living.

The physical impacts identified in this study were dental erosion causing pain and tooth sensitivity, brittle teeth prone to breakdown, enamel loss causing reductions in the occlusal vertical dimensions, and impaired aesthetics. These findings are consistent with other studies which reported dental erosion as the most common oral health problem in patients with EDs [7, 15]. The Johansson et al. study found that patients with EDs were 8.5 times more likely to have dental erosion compared to healthy controls [6]. In our study, pain with highly sensitive teeth was more commonly expressed by the younger participants, comparable to other studies on adolescent patients with EDs [16, 17]. The formation of secondary dentin over time may be a reason why the older patients in this study reported fewer symptoms of sensitivity from their teeth. However, the physical impact of impaired aesthetics with shortened, damaged, yellow, and unpleasant looking teeth impaired the patient’s ability to socialize and eat with others, causing a negative impact on oral health-related quality of life, which the Lo Russo study also described [15].

None of the participants in this study expressed dental fear, in contrast to other studies [6, 15]. On the contrary, all participants in this study stated that they had sought dental care several times, sometimes over a period of 10–15 years, and all had an objective need for dental treatment. The participants felt they were overly preoccupied with the condition of their teeth and had a constant fear of dental breakdown, comparable to other patient groups with risk of dental breakdown [18].

All participants in this study reported feeling stigmatized, from having suffered from a mental disorder, which Crisp et al. also described [19], and from living with poor oral health. All participants also expressed guilt due to having inflicted the dental damage on themselves. Some participants described the aftereffect of having an ED like battling a war with oneself and constantly loosing, which Williams & Reid also described [20].

Fear of shame for being exposed as having had an ED was another feeling that was expressed. The shame might have been higher for our study participants than for other groups since the participants were well educated and expectations on them for maintaining good oral health were high.

There is support in the literature for how poor oral health and untreated oral diseases can significantly impact quality of life, including loss of self-esteem and decreased economic productivity [21]. Quality of life can be intangible and difficult to define. “Oral health, although generally not life threatening, can affect the way one eats, speaks, and socializes. Hence, poor oral health can have a profound negative effect on interpersonal relationships, self-esteem, and quality of life” [21, 22].

Several participants also expressed a feeling of being a failed anorectic, which caused even more shame since anorexia nervosa has a higher status in the public in general, and in the community of EDs. The scoping review of Brelet et al. also describes this experience, highlighting the underrepresentation of research on bulimia nervosa and binge-eating disorder compared to the interest in anorexia nervosa [23] The review noted as well that stigma content differs between different EDs [23].

Low self-esteem linked to poor oral health was another feeling the participants expressed. This is consistent with Huff et al. who state that oral health problems affect self-esteem to the same extent as other health related conditions, such as cancer, diabetes, high blood pressure, and asthma [22]. The research group also stated that “The face is the very core of human identity” and that individuals with poor oral health may feel self-conscious and embarrassed, which limits social interaction and communication [22]. Self-image and self-esteem are integral components of one’s ability to reach full psychosocial potential [24], which agrees with our findings.

Poor oral health can interfere with building self-esteem and other types of psychological development; in fact, self-esteem may have more potential for predicting health behavior than other more specific personality measures [24]. However, the effects of deteriorated oral health on self-esteem have not been a priority among health care providers for vulnerable populations, such as patients with EDs. In their study on the experience of Norwegian dentists who treated patients with EDs, Johansson et al. found a lack of knowledge and difficulty meeting the needs of this patient group [25].

The Norwegian dentists expressed difficulties in making contact with, treating, and even getting along with patients with EDs [25]. Other studies confirmed these findings of a lack of knowledge among dental health care professionals regarding meeting the dental needs of this patient group [8, 9]. These results are consistent with the results of the present study where nine of the ten patients interviewed expressed repeated unmet needs in contacts with dental care. How these participants have experienced dental care, and which needs and expectations of dental treatment they have expressed will be described in another study.