Dentistry and eating disorders
Picture this scenario. A fifty year old patient presents with heavily restored and failing dentition. Bulimia is clearly indicated and you are facing the dilemma of how to correctly broach this delicate subject so that you can effectively discuss her options for treatment.
Bulimia nervosa is one of the most prevalent eating disorders in the UK; usually arsing during adolescence.
The oral health complications caused by repeated intentional vomiting are well recognised and include:
- Changes to teeth surface character; smooth and rounded teeth which are sensitive
- Thinning of the incisal edges which become translucent and may chip
- Loss of enamel resulting in dentine erosion and cupping of cusp tips
- Shallow, rounded cervical lesions
- Protruding fillings which have been unaffected by the erosion which has damaged the rest of the tooth
- Erosion at the edges of crowns – gaps may be apparent
The first discussions
Early discussions must be sympathetic and non-judgmental in which the findings of your examination should be explained. If you have provided the time and space for these discussions to take place, the patient will have the opportunity to make the link between their dental problems and their eating disorder. However, bulimia is characterised by denial and even shame and so immediate and open discussions are not guaranteed. Further encouragement can be given by explaining that their teeth are showing signs of acid damage and that there are several ways in which acid can contact teeth. Food, drink and stomach acids are the three main sources. This gives the patient the opportunity to discuss the role of stomach acid without necessarily admitting the presence of their own eating disorder. Over several sessions you will be able to re-enforce your role in protecting their dental health and provide a source of motivation for reducing the habitual vomiting. It must be stressed that bulimia is a long-term condition affecting patients for many years. It is also not constant and your support will be required through both its more active and inactive phases.
Treatment is aimed at relieving pain, reducing sensitivity and improving dental appearance. This, in turn, should serve as a motivator for the patient to address the underlying condition. A multi-disciplinary approach is advised; general practitioners can prescribe medications to tackle co-morbidities that add to the dental problems such as acid reflux and dry mouth caused by anti-depressants. Close liaison with the patient's nutritionist and/or psychiatrist will allow you to assess the likelihood of further dental deterioration. Advice features prominently in the early stages of treatment and emphasises the effect of acids in foods and drinks on the teeth. Practical steps include:
- Replacing acidic drinks such as fruit juices with water or milk
- Drinking acidic fruits with a straw that delivers the drink at the back of the mouth – effectively by-passing the teeth
- Avoiding contact between the acidic drink and teeth by not swishing the drink around the mouth and by swallowing promptly
- Using a fluoridated mouthwash or water to rinse the mouth after consuming acidic beverages
Patients with bulimia can further help their dental health by:
- Using fluoride rinse or gel as well as using high fluoride toothpaste every day
- Rinsing with a fluoridated mouth wash after vomiting - sugar-free xylitol-sweetened gum can also be used whereas immediate brushing should be avoided.
In patients with on-going bulimia, definitive restorative treatment is not indicated; further deterioration is inevitable. Nevertheless, it is paramount to take steps to protect the surviving dental structures.
A tooth mouse containing calcium and phosphate ions may be effective in restoring the mineral balance, neutralising the effects of acid and stimulating the production of saliva.
Visual tools such as study casts and photographs have proved useful in aiding communication with patients as the treatment is progressing. There may some benefit in directly applying glass ionomer, composite resin or other adhesively-retained filling materials to areas that are sensitive. Soft mouth guards used in conjunction with alkali or fluoride gel afford the teeth some protection during vomiting and should be removed immediately afterwards.
The bottom line
The situation can only be handled effectively with both sensitivity and understanding. The potential for dental improvements can provide a further motivation to tackle the underlying bulimia. Although broaching the subject at first is always going to be difficult, it is the first hurdle in achieving a partnership between you and your patient that will hopefully tackle this devastating psychological condition.