Bulimia from a dental standpoint

 Two articles dealing with the diagnosis of bulimia from a dental

standpoint...Database search BRS Colleague 5/19/89

AN YBDN-811015.  88093.

AU Abrams, Richard A.; Ruff, Jesley C.

IN Marquette Univ.

TI Year Book: Oral Signs and Symptoms in the Diagnosis of Bulimia.

SO Abstract/Commentary:

   1988 Year Book of Dentistry. Article 11-15.

   Original Article:

   J. Am. Dent. Assoc. 1986 Nov. 113. pp 761-764.

PU Copyright (c) 1988 by Year Book Medical Publishers, Inc.

PD 880000.

PT Abstract (ABS).

IS 0084-3717.

LG English (EN).

AB For abstract and commentary see text.

   ABSTRACT

   Bulimia is characterized by repeated episodes of binge eating and

   self-induced vomiting (Fig 11-13).  Patients fear being unable to

   stop eating voluntarily and tend to be depressed after eating binges.

   Preoccupation with body weight is a frequent finding.  Typically,

   young females are affected.  Apart from vomiting, patients may fast

   or use cathartics or diuretics.

   Bulimic patients may exhibit enamel erosion, salivary gland

   enlargement with xerostomia, irritation of the oral mucosa, and

   cheilosis (table).  Enamel erosion (Fig 11-14 and 11-15) results

   from chronic regurgitation of gastric contents having a low pH.  In

   severe cases the incisal edges of anterior teeth are eroded, thus

   producing shorter clinical crowns.  If the process involves the

   posterior teeth, enamel erosion can close the bite (Fig 11-16).

   Thermal tooth hypersensitivity is fairly common.  The parotid, and

   occasionally the submandibular, gland may be enlarged.  Oral mucosal

   erythema may result from chronic irritation by gastric contents.

   Cheilosis may reflect both local irrigation and systemic factors,

   e.g., vitamin deficiency.

   Enamel erosion on the lingual and occlusal surfaces of maxillary

   teeth is characteristic of bulimia.  Recognition of this and other

   oral consequences of bulimia may facilitate early diagnosis and

   preclude the need for certain laboratory tests.

   COMMENTARY BY R.  JOHNSON, D.D.S.

   The five basic oral signs and symptoms of patients with bulimia are

   reviewed in this paper.  Awareness by the clinician can facilitate a

   diagnosis of bulimia during routine examination and history

   documentation.--R.  Johnson, D.D.S.

AN MJMA-860622.  86072.

AU Simmons, Mark S., D.D.S., M.A.; Grayden, Sharon K., M.A.; Mitchell,

   James E., M.D.

IN From the Family Practice Dental Clinic, University of Minnesota

   School of Dentistry, Minneapolis; and the Eating Disorders Clinic,

   Department of Psychiatry, University of Minnesota Medical

   School--Minneapolis. Address reprint requests to Dr. Mitchell, Box

   393 Mayo, University Hospitals, 420 Delaware St., S.E., Minneapolis,

   MN 55455.

TI Clinical and Research Reports: The Need for Psychiatric-Dental

   Liaison in the Treatment of Bulimia.

SO American Journal of Psychiatry. 1986 Jun. 143(6). pp 783-784.

PU Copyright 1986 American Psychiatric Association.

PD 860600.

PT Article (ART).

IS 0002-953X.

LG English (EN).

AB      During dental examinations 38% of 66 outpatients with bulimia

   were found to have evidence of significant enamel erosion, and

   chronicity of vomiting was significantly associated with erosion.

   Liaison with colleagues in dentistry is necessary when working with

   bulimic patients.

        (Am J Psychiatry 143:783-784, 1986).

        The eating disorder bulimia is increasingly recognized as an

   illness with significant medical complications, including fluid and

   electrolyte abnormalities, salivary gland hypertrophy, and the risk

   of gastric dilation *RF 1 *.  However, one of the most common

   complications of bulimia is dental pathology, which most

   psychiatrists and nonpsychiatric physicians know very little about

   but which can be associated with significant morbidity and

   considerable expense *RF 2 *.  Previous reports *RF

   2,3,4,5,6,7,8,9,10 * have suggested several types of dental changes

   presumed to be associated with both bulimia and chronic vomiting

   from other causes; such changes include increased temperature

   sensitivity, enamel erosion, and an increased rate of caries

   development.  However, to our knowledge no studies have

   systematically examined the prevalence of specific types of dental

   pathology in patients with bulimia.  Therefore, this article will

   present data on the prevalence of dental problems in a group of

   bulimic patients and will also review practical advice that mental

   health professionals can offer to these patients to minimize the

   dental consequences of the behavior.

   METHOD

        Patients who are evaluated in the Outpatient Eating Disorders

   Clinic at the University of Minnesota are asked routinely to have a

   free dental examination as part of the intake evaluation.  The

   purposes of the dental evaluation are to assess each patient's

   dental status and to discuss with the patient means for minimizing

   bulimia-related damage.  When seen in the dental clinic, subjects

   complete a detailed survey that asks questions about abnormal

   eating-related behaviors and undergo a dental examination by two of

   us (M.S.S.  and S.K.G.).  In this series we included only bulimic

   patients who were thought to have a significant problem with

   vomiting--defined as at least three episodes of vomiting a week at

   the time of evaluation.

   RESULTS

        The patient group consisted of 66 white, female outpatients who

   satisfied the DSM-III criteria for bulimia and the additional

   frequency criterion of self-inducing vomiting at least three times a

   week.  During the period of study a few potential subjects refused

   dental examination, often indicating that they were already being

   seen for dental problems by a private dentist.  The median age of

   the patients was 26 years (range=18-34); mean duration of illness

   was 7 years.

        Erosion was diagnosed clinically if observable, and borderline

   cases were not counted as evidence of erosion.  Erosion was

   indicated by shiny, smooth enamel, loss of vertical dimension, lack

   of staining, rounded contours, and fillings that projected above the

   surface of the teeth.  In many cases the enamel was completely lost

   in certain areas and dentin was exposed or nearly so.  Overall, 25

   patients (37.9%) had evidence of significant erosion.

        The presence or absence of erosion was related to the duration

   of vomiting.  The prevalence of erosion in the patients who reported

   vomiting for 2 years or less was 25.0% (two of eight), the

   prevalence for those who reported vomiting for more than 2 years to

   4 years was 24.1% (seven of 29), the prevalence for those who

   reported vomiting for more than 4 years to 6 years was 50.0% (eight

   of 16), and the prevalence for those who reported vomiting for more

   than 6 years was 61.5% (eight of 13).  The prevalence of erosion in

   those reporting vomiting for 4 years or less (24.3%, nine of 37) was

   significantly lower than the prevalence of erosion in those

   reporting vomiting for more than 4 years (55.2%, 16 of 29) chi sup

   2=5.53, df=1, p<.05).

        Although rampant caries development has been mentioned in the

   literature as a sequela to bulimic behavior, extensive, clinically

   detectable caries (minimum of two carious lesions) was observed in

   only two patients.  Other than the dental erosion, the dental

   hygiene of these patients appeared quite satisfactory.  Most of

   these individuals would be considered good dental patients--53

   (80.3%) had seen their dentist in the past year, 49 (74.2%) stated

   that they brushed their teeth two or more times a day, and 45

   (68.2%) stated that they flossed with some regularity.

   DISCUSSION

        The current results suggest that patients who have vomited

   frequently for a long period of time are at risk for developing

   significant dental erosion and that the majority of patients who

   have been actively bulimic and vomiting at least three times each

   week for more than 4 years will evidence such changes.  It is

   probably safe to assume that our findings underestimate the

   prevalence of erosion, since some of the patients who refused

   examination did so because they were already under dental care,

   commonly for bulimia-related problems.  Serious erosion of the

   magnitude described in this study is very uncommon in the general

   population and when observed is usually found to be associated with

   a physical or emotional problem that predisposes to vomiting, such

   as hiatus hernia or psychogenic vomiting.  In contrast to the

   suggestion made previously *RF 2 *, our data do not indicate a high

   rate of caries development in this patient group.

        It must be remembered that the data on bulimia duration and

   frequency were based solely on self-report, which is not always

   reliable in this population.  In addition, the current study does

   not adequately answer the question of why certain patients do not

   develop erosion despite chronic, frequent vomiting.  It is certainly

   possible that dental hygienic practices may help prevent the erosion.

   Washing out the mouth after vomiting, using bicarbonate rinses (to

   neutralize the residual gastric acid in the mouth after vomiting),

   and using fluoridated dentifrices and mouthwashes or topical

   fluoride treatment may minimize the destructive effects of the acid

   and strengthen the teeth against further erosion.  However, the

   utility of these practices will need to be tested in a larger

   sample, and future research in this area should carefully examine

   such practices and their relationship to erosion.  Pending further

   study, consideration should be given to recommending that bulimic

   patients use fluoridated mouth rinses daily, that if they continue

   to vomit they rinse their mouths with bicarbonate rinses shortly

   after vomiting, and that their dentists consider topical fluoride

   treatments.

        The relationship between brushing and erosion is less clear.

   Fifty percent of those who brushed after every vomiting episode had

   evidence of erosion, suggesting that this practice does not protect

   against erosion and lending some support to the possibility that

   brushing the teeth immediately after vomiting may actually

   exacerbate erosion by promoting enamel loss shortly after the teeth

   have been etched by the acid.  However, the alternative view, that

   brushing immediately after vomiting may be useful in removing acid

   and therefore preventing erosion, has not been disproven.

        These results suggest that dental complications may be commonly

   encountered in patients with bulimia and that psychiatrists should

   explain this problem to their patients, discuss what is known about

   mitigating its development, and consider the advisability of dental

   evaluation of bulimic patients.

        Received Oct.  21, 1985; revised Feb.  3, 1986; accepted March

   3, 1986.

          REFERENCES

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   binge-purge syndrome (bulimia): report of cases. J Am Dent Assoc

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        3. Guernsey L. H.: Gastric juice as a chemical erosive agent:

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   Perimylolysis: unveiling the surreptitious vomiter. Oral Surg

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        10. Simmons M. S., Grayden S. K., Salmen G. W.: Dentist's role

   in diagnosis of bulimia via screening for erosion (abstract). J Dent

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