Cosmetic Dentistry for Patients with Bulimia
Important considerations before, during, and after dental treatment
Eating disorders can be extremely serious illnesses that require psychological and physical intervention on several fronts. Anorexia nervosa, bulimia nervosa, and unspecified eating disorders involve an altered self-perception of body weight and morphology. A hallmark is dysfunctional eating, which can include dieting, fasting, binge eating, restricted eating, and/or frequent vomiting after eating. In many cases, these behaviors are driven by psychological rather than biological factors. Young women are especially vulnerable, but eating disorders can occur at any age and in either sex. Athletes can be at risk because certain sports require low or high weights to meet qualifications.
Prevalence and Dental Ramifications of Eating Disorders
According to Doug Bunnell, PhD, a founder and past board chair of the National Eating Disorders Association (NEDA), eating disorders are still under-detected and under-diagnosed. Nevertheless, it is estimated that 35% to 57% of adolescent girls use crash diets, fasting, or self-induced vomiting as a means of maintaining or losing weight.1 More than 50% of teenaged girls and one third of teenaged boys exhibit unhealthy weight-control behavior.2 The incidence of bulimia in females between ages 10 and 39 years tripled between 1988 and 1993.3 Current figures suggest that between 1.1% and 4.2% of women have bulimia symptoms during their lifetime.4 Approximately 0.9% of females are classified as anorexic.5 Many others show some signs of one or both conditions but are not classified as either.
Dentists may have the unique opportunity to be the first health care professionals to identify bulimia and other eating disorders in patients; in fact, 28% of patients with bulimia are first diagnosed during a dental exam.6 Although a comprehensive discussion of the symptoms and presentations of various eating disorders is beyond the scope of this article, NEDA has an abundance of resources to help health care professionals develop an educated and compassionate approach.4,7
The dental and medical ramifications of eating disorders become more severe the longer the condition exists.8 An estimated 89% of patients with bulimia exhibit worn tooth enamel and decayed and sensitive teeth.8 This is due to stomach acids that invade the lingual enamel of upper anterior teeth from the binging and purging associated with bulimia. Acid reflux disorder and other gastrointestinal problems can further damage the oral environment. Eventually, the loss of enamel can cause alterations in shape, length, and color of the anterior teeth. A loss of vertical dimension and major changes in occlusion can occur.
As the condition worsens, salivary glands and ducts may swell in the neck and jaw. This swelling can result in widening of the corners of the jaw, leading to a square-jaw appearance. Lips redden, dry, and crack, and the patient may complain of resultant dry mouth and temporomandibular joint (TMJ) symptoms, which result from the previously stated changes. Other symptoms include electrolyte imbalance that can lead to inappropriate levels of calcium, sodium, and potassium. At its worst, this can lead to heart attacks, stroke, or even mortality.
Treatment Considerations for Patients with Bulimia
Shame and ambivalence make treatment of eating disorders difficult. Bunnell suggests that issues of past or present trauma, anxiety, and depression complicate treatment and long-term prognosis. NEDA has guidelines for initiating difficult conversations with patients suspected of having bulimia.7 The dental team should recommend seeing a physician, nutritionist, and counselor for non-dental treatment. To assist, NEDA can be reached at www.nationaleatingdisorders.org or 800-931-2237 and can serve as a resource for dentists and patients alike.
Recovery is the time when long-term cosmetic dentistry will have the best prognosis. The dentist and patient must decide if the time is right. A thorough new-patient interview is essential prior to initiating dental treatment. Patients with eating disorders may be embarrassed or even defensive about their conditions. Therefore, empathy is essential for creating a bond. A comprehensive examination is also important, as the teeth, muscles, and joints can be damaged by the acid entrenchment from bulimia.
Dental treatment can be accomplished in different ways. Clearly, active decay, infection, and other pathology must be treated. If the condition is still acute, long-term temporization of anterior teeth without enamel makes more sense than permanent porcelain restorations, which may have to be redone due to continued acid infiltration in the area. In many cases, orthodontics is essential because the patient’s bite will change as lingual enamel is destroyed. Occlusal space must be added to allow for protection of the lingual dentin of these teeth unless all maxillary teeth are treated with crowns. Short-term orthodontics can be used in some cases. If an orthodontist provides the patient with treatment, excellent communication between the restoring dentist and specialist is essential. This article presents a rare case in which orthodontics was not deemed necessary for conclusive treatment.
A 31-year-old woman presented to the office with an interest in restoring severely worn upper anterior teeth (Figure 1 through Figure 3). The lingual surfaces of these teeth were badly eroded, and the teeth were extremely short after the loss of perhaps 30% of tooth structure. A review of the patient’s medical history revealed that the patient had a history of bulimia. She stated that she was in recovery and had not regurgitated as part of her past condition for 1 year. She was excited about beginning treatment as soon as possible to restore her teeth. She consented to occlusal analysis and photographs and stated that she would consider short-term tray orthodontics but would not consent to full-banded orthodontics. She also said she had had “mild dislocation” of her left TMJ in the past.