The perils of bulimia nervosa
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By George Malkemus  October 11, 2013 12:00 am

Very early in my dental practice, I encountered my first bulimic patient.  A beautiful, healthy 26-year-old woman had listed a previous medical history of bulimia nervosa in her adolescent and college years.  

She had beaten the disease after several years of counseling in her early 20s.  Her chief complaint was extreme cold sensitivity on her teeth.  Upon examination, I found her upper front teeth extremely worn on the inside. In fact, her front teeth were nearly paper-thin. She had lost almost all enamel from the inside surfaces.  She had a beautiful smile with the front of her teeth perfectly normal.  The acid from her bulimic vomiting along with a nervous grinding habit had eaten the inside of her teeth away.  I made her a protective mouth guard to wear and gave her a desensitizing surface protection fluoride rinse to use, along with good oral hygiene instructions.  

She turned 54 this year and I am happy to state she still has the same teeth.  Wonderfully, she has maintained her teeth extremely well over the last 27 years through great oral hygiene, the use of a mouth guard and regular dental cleanings. She dedicated herself to health, chose a career as a health professional, becoming a successful physical therapist, and has helped thousands of people over the years. All too often the stories of people suffering from bulimia do not end so well.  I researched bulimia on the Internet and was deeply moved and saddened by the testimonies I read and videos I viewed.

What is Bulimia?

Bulimia is an eating disorder that is characterized by episodes of binging and purging, usually self-induced vomiting.  Bulimia is a Latin word derived from the Greek term for “ox hunger.”

Bulimia nervosa is characterized by uncontrolled ingestion of huge quantities of food, followed by either involuntary or, more usually, self-induced vomiting.  The affected person feels a considerable loss of control during eating and feels it is impossible to stop eating. During a single session, an individual may consume any where from 3,000 up to as much as 20,000 food calories. Typically the food is sweet or starchy and is often swallowed with little or no chewing. 

In order to prevent weight gain, a bulimic individual will use recurrent, inappropriate behavior, such as self-induced vomiting, misuse of laxatives, diuretics or other medications, extreme fasting or excessive exercise. The most common is vomiting. The average patient induces vomiting at least once a day, and even more often during times of emotional stress. This activity is usually done late in the evening when it is not uncommon to vomit four to six times. 

This disorder can produce a variety of metabolic and electrolytic imbalances, especially when combined with abuse of laxatives, diuretics and thyroid hormone replacement medications. Abdominal pains and problems are a frequent occurrence.  Dehydration is common and the skin and mucous membranes frequently become dry. 

Bulimia nervosa is a major problem among young women and has been described as an “epidemic” affecting as many as 13 percent of female college students. More than 85 percent of affected patients are young women with a mean age of 19 years, but cases have been diagnosed in persons as young as 12 and older than 35.   The presence of all types of eating disorders is related to our modern cultural obsession with thinness in women. This cultural obsession endangers the lives of thousands of people, especially young people.    

Without successful treatment, one in 300 bulimic cases will have a fatal outcome. Even with treatment, one third of affected individuals suffer early relapse and half do not consider themselves cured five years after psychological therapy. Early diagnosis is important because the treatment of early cases is much more successful. Unfortunately, most cases are not diagnosed until 6-8 years after the onset of the eating disorder. 

Psychological aspect of bulimia

Bulimia nervosa is a disease with a predominantly psychological origin. Individuals suffer from almost a terror of being rejected and a constant need for approval from others.   They are usually in denial about their problem and are secretive, ashamed, guilt-ridden and self-deprecating about their abnormal eating.  They often become depressed. 

A large proportion of bulimic patients report significant physical and sexual abuse during their early years.  Three of every four affected women have serious anxiety disorders, and almost half develop alcohol or another drug dependency. 

The treatment for bulimia nervosa is primarily psychiatric or psychological counseling, but only 50 percent of bulimia nervosa patients consider themselves fully recovered 5-10 years after treatment.  Approximately one-third of treated patients will suffer a relapse within four years after treatment. 

Physical changes are often slight or completely lacking and along with the individual’s secretiveness, the disease can go unnoticed. Even an examining physician is unlikely to detect this serious, potentially life-threatening disease until late in its progression.  Actually, the dental manifestations of bulimia nervosa may be the first and only visible sign of the disease.

Dental signs of bulimia

The erosion of the enamel in the inside of the upper front teeth is the first and most common physical effect seen in bulimics. Habitual vomiting throws stomach acid against the back of the upper front teeth, causing the protective enamel coating to dissolve away and uncovering the underlying dentine. The teeth become much more sensitive to hot, cold and acidic foods because nerve endings in the underlying dentine layer become exposed. Dental cavities become more numerous because dentine is much softer than enamel and much more susceptible to decay. The edges of the upper front teeth become more and more thin and translucent, eventually producing knife-edges that easily chip.         

Not all of the oral changes of bulimia are tooth related. Parotid gland swelling is common in bulimics with a slight bulge beneath the ear.  Dry mouth with reduced salivary flow is common, especially with laxative abuse.  Chronic sore throat is often found from recurring vomiting.  Commonly red, burning sores appear in the corners of the mouth caused by the exposure to acid during vomiting.        

Trauma to the soft tissue can occur from injury caused by force vomiting.

Scratch marks on the soft palate may be seen to result from fingernails injuring the mucosa when the patient sticks her finger deep in the throat to induce vomiting. This chronic habit can, likewise, lead to the development of scars and calluses on the back of the finger used to induce vomiting.

Dental treatment

Treatments for enamel loss include the use of desensitizing agents at home or in the dental office, as well as fillings, crowns, or laminates to cover missing enamel. And if any nerves have died, root canal treatments must be taken care of as well. Starting a rigorous hygiene and home care program is vital to continued success. 

But most important, bulimia patients must seek psychological counseling to stop the cycle of damage not only to their mouth but also to their whole body. A referral to a mental health professional that is experienced in eating disorders is best.

Enjoy life and keep smiling.

George Malkemus has had a Family and Cosmetic Dental Practice in Rohnert Park at 2 Padre Parkway, Suite 200. Call 585-8595, or email info@ malkemusdds.com.  Visit Dr. Malkemus’ website at www.malkemusdds.com.

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