Strive-the Student View
November, 2006 edition

Bulimia and Its Implications for Oral Health

 
By Kimberly S. McCreedy

Mirror, mirror on the wall, who is thinnest of them all? Perhaps this question sounds absurd to the reader who has not been exposed to the debilitating disease known as bulimia. However, to those who have battled this serious illness, as well as to those individuals who have watched a loved one suffer, the question serves as a reminder that bulimia is not only an eating disorder, but also a psychiatric compulsive disorder that often goes unrecognized and untreated. In fact, bulimia is life threatening without psychiatric and medical intervention.

In 1980, the American Psychiatric Association first acknowledged bulimia (derived from the Greek words for "ox" and "hunger").[1] Bulimics have an obsession with food intake and body image characterized by repeated consumption of voluminous quantities of food, followed by compensatory behaviors such as vomiting, repetitive exercise, and laxative and diuretic abuse. Bulimia has been described as an epidemic on college campuses in recent years.[2-5] More than seven million people suffer from eating disorders and 85% of diagnosed patients that present for treatment are women with a mean age of 19. However, there have been individuals as young as 9 years of age and older than 35 years of age who have been diagnosed.[2] Further, it has been estimated that one in three hundred cases of bulimia will have a fatal outcome without successful intervention. This is why we, as future dental health professionals must be knowledgeable about the oral manifestations of this disease. Bulimics may be able to hide their disorder from friends and family; however, the secret is often hard to keep from an informed dental professional.

Oral Manifestations and the Bulimic Patient

As we know, the oral cavity is often the first place that signs of systemic disease manifest themselves. Dental professionals are therefore at the forefront of recognition and diagnosis of disease. Bulimia is unique in that the presentation of symptoms in the oral cavity is very apparent. Consequently, the clinician can view the earliest cases of bulimia, even before other health professionals. Due to these facts, it is imperative that we as hygienists be well informed about the oral presentation of the bulimic patient and recognize the visual signs.

The typical bulimic patient is a Caucasian female presenting with calluses near the first knuckle of the index finger as a result of the maxillary incisors scraping the epidermis when the patient attempts to induce vomiting. Decreased salivary flow causes dry lips, commissures and xerostomia; and parotid gland dysfunction may be present. Characteristics typical of bulimic patients are abrasion from excessive tooth brushing and enamel erosion of all teeth due to chronic exposure to stomach acid in vomit. Often, enamel erosion is most recognizable on the palatal surfaces of the maxillary anterior teeth. Dentin is often exposed, and it is not unusual for the cingulum to be worn away in more progressive stages of bulimia. Further, 35-70% of bulimics suffer from depression and have an increased risk of heart attacks due to electrolyte imbalance resulting from nutritional deficits.[3]

Dental erosion is the number one indicator of chronic vomiting. We must make a differential diagnosis to rule out other reasons for dental erosion such as gastroesophageal reflux disorder (GERD). When we think of erosion, we typically think of the facial and lingual surfaces of the dentition.[5] However, due to the fact that facial surface erosion would be more characteristic of dietary habits such as sucking on lemons or consuming other acidic foods, one would expect to find erosion on the lingual rather than the facial surfaces of the bulimic patient, due to the purging behavior which accompanies the disease. The clinician may also look for patterns of erosion, keeping in mind that mandibular posterior teeth are often protected from stomach acid due to the anatomy of the tongue.

In addition to dental erosion, the systemic effects of bulimia are another important warning sign of the disease. Xerostomia can result from dehydration due to vomiting or the abuse of laxatives or diuretics. The clinician should palpate the parotid gland thoroughly and make careful observation of any swelling, since enlargement can indicate the length of time as well as the complexity of the purging behavior, such as how often the purging behavior occurs in one day. Oral manifestations of trauma can be recognized by carefully observing the interdental papillae, marginal gingiva and the soft palate. Trauma to these areas can be a result of forced vomiting. Finally, amalgam restorations may appear raised as a result of acid eroding the crown.[6]

The dental hygienist can play a critical role in the recognition and introduction of life-saving treatment for the bulimic patient because they are in the position to recognize the signs and symptoms of bulimia. In a 2002 survey by researchers at the University of North Dakota, 22% of hygienists interviewed revealed that even when they suspected a patient might have an eating disorder, they rarely or never mentioned it.[7] We must be co-therapists with our patients. Therefore, it is critical to voice our concern. Often, patients feel comfortable with the hygienist, which is why we must seize the opportunity to intervene. We could be saving an individual life, and that represents one of the many reasons that we have chosen a health care profession.

Dental treatment of the diagnosed bulimic patient includes regular dental hygiene. Fluoride applications can prevent further erosion and decrease hypersensitivity.[8] The use of saliva substitutes or sugarless chewing gum can help to improve xerostomia. Patients with bulimia should rinse vigorously with water after purging to lower acidity within the oral cavity. Finally, toothbrushing following a binge and purge episode is contraindicated, since it can lead to additional enamel erosion.[9]

As a future licensed health care professional, I look forward to implementing what I have learned and experienced with all facets of dental hygiene care. I feel it is important to strive to obtain new knowledge and apply those educational experiences to best serve my patients. It is my hope that as professionals we can make a difference in someone's life as co-therapists for preventive dental care as well as systemic disease recognition. Bulimia is a life-threatening disorder. Through knowledge, continuing education and awareness, you may save a life.

References

1. Bourquot JE, Seime RJ. Bulimia nervosa: dental perspectives. Pract Periodontol Aesthet Dent 1997; 9: 655-64. Available at http://maxillofacialcenter.com/bulimia.html.
2. Aesthetic Dental Creations. Bulimia and oral health. Dental Venue 2003. Available at www.dentalvenue.com/bulimia.html. Accessed Jun 27, 2006.
3. The Medical Reporter: Dental hygienists are especially adept in detecting eating disorders bulimia and anorexia. Available at medicalreporter.health.org/tmr0499/american_dental_hygienists.htm>.
4. Fairburn CG. Studies of the epidemiology of bulimia nervosa. Am J Psychiatry 1990;147: 401-8.
5. Fallon P, Klump K. International conference of eating disorders. Academy for Eating Disorders. 2005. Available at www.aedweb.org. Accessed Feb. 4, 2006.
6. Fehrenbach M, Baker-Eveleth L. Dental erosion: case based learning for dental hygiene treatment. Marquette University. Marquette Educational Consultants. 2003. Formerly available at www.marquette.edu/dhforum/erosion.htm. Accessed Dec. 5, 2005.
7. Mabrito CA. Eating disorders: general and cosmetic dentistry. 2001. American Academy of Cosmetic Dentistry. Available at http://www.mabrito.com/EatingDisorders.htm. Accessed Jun. 27, 2006.
8. Russell G. Bulimia nervosa: an ominous variant of anorexia nervosa. Psychol Med 1979; 9: 429-48.
9. Saving your teeth: first, reconsider when to brush. Eating Disorders Today 2002; 1(3). Eating Disorders Resources. Available at www.gurze.net/site12_5_00/newsletteredt6.htm. Accessed Dec. 5, 2005.

Kimberly S. McCreedy is a full-time mother of two children as well as a full-time dental hygiene student at Harper College in Palatine, Illinois. She looks forward to graduating in 2007.