The first line of defense: recognizing bulimia through dentistry

By Michael Kraus, DDSBulimia is a digestive order disease, which afflicts millions of people in the United States. Predominantly — but not exclusively — in young people, bulimia is a disease that links psychological problems with dysfunctional habits, eventually resulting in severe physical implications. Bulimia is a behavioral disease where an individual alternatively binges and purges his or her meals. Girls and young women between the ages of 14 and 20 are by far the largest segment of the population of bulimic patients.Struggling with issues of self-image and peer acceptance, constant dieting is part of what teens come to accept as "normal" through their teen and college years. In fact, in many cases, job pressures and the pursuit of a mate can extend that weight consciousness far beyond those years. Still, the dieting is at least for most individuals under their control. However, combining that acceptable norm with the added pressures of present day culture as seen in all forms of media, it is no wonder why young women especially will do anything they can to lose weight. Weight loss becomes the obsession. If they give in to increased urges of hunger during the day, then they may also succumb to purging themselves after eating. This cycle then repeats itself after every meal until it becomes the norm rather than the exception.Bulimic patients often suffer from depression, anxiety, sleep deprivation, malnutrition, and not insignificantly, dental problems. Erosion of the dentition can come from several different means. First is the constant drinking of acidic juices such as orange juice or sucking on fruit with high citric acid content. Often these individuals are under the impression that you just can't have too much Florida orange juice. But without neutralizing the acid, both the individual’s teeth and digestive system will ultimately take a hit, especially if allowed to sit overnight. Parents are always told to mix juice with water to a 50/50 dilution in order to reduce both sugar and acidic content.Erosion also occurs when xerostomia, or dry mouth, is present as in diseases such as Sjögren’s disease. The natural protective enzymes in saliva are not present to fight tooth decay, and the teeth wear and erode. It is often hard to restore these patients to their original dental state, as the enamel is worn and the exposed dentin is difficult to bond to or to use various cements common to cosmetic dentistry.Finally, erosion occurs when the dentition is constantly bathed in stomach acids. Although bulimia is not the only time we see excessive regurgitation, the physician often misses it when there are no other clues present. Often it is up to the dentist to identify cases of bulimia. Young adults who may be closemouthed about their problems and habits when it comes to parents and loved ones may be perfectly willing to open up wide and say "ah." They often don't know there could be any dental or oral repercussions or clues beyond bad breath, which they often go to great lengths to cover up. It is up to the dentist to ferret out these patients and to have the tough discussions needed to bring the disease of bulimia to the surface.There are a host of HIPAA and psychological issues to consider here, of course. Generally, however, these patients are horrified to learn what the consequences of repeated purging can be. If they already have significant wear, it is easy to show with photos the status of their teeth. Often, the same insecurity that led them down the path to bulimia will be the very thing that will shake the behavior when we show them a possible future of their smile. In many cases, the patient’s smile is just as important to the self-image as weight and figure, but much, much more expensive to redo.The hardest thing with bulimic kids is to get them to admit there is a problem and to peacefully involve loved ones and professional help. Sometimes poor self-image starts at home, and it is unlikely that the child would want to let his or her parents in on the treatment. That is when a school counselor, psychologist, or outpatient clinic is the way to go. As dentists, however, we are perhaps the first line of defense against this dreadful disease. It is incumbent upon us to be vigilant and look out for its unknowing victims. It is important for us to spread the word to pediatricians and physicians. A simple mouth exam, something that physicians of yore routinely administered, may be all that is needed to pick up on the signs of a bulimic patient. At the Center for Living in NYC in particular, doctors deal with all types of addictions and discuss numerous issues with young patients and their families. This is but one example. What a difference you can make alerting families and physicians about this insidious disease.