Diagnosing Bulimia

by Gloria Alban, DDS, RHN

bulimiaIn the September 2016 issue of this journal, I shared information about how the dental professional can help patients with their general and oral health through the diagnosis of acid reflux, a condition that affects up to 50% of the population. In this article, I discuss bulimia, an eating disorder which in the early stages can mimic the oral manifestations of acid reflux disease. Bulimia is a very serious chronic illness affecting 1-3% of women and a lower but significant number of men. I hope that by reading this article you become more aware of this illness in your patients and also feel comfortable in knowing how to approach the topic with them.

What is Bulimia Nervosa (Bulimia)
Bulimia Nervosa is an eating disorder characterized by bingeing and purging. Typically, binges tend to be large quantities of food eaten in a manner that feels out of the patient’s control. The patient cannot stop eating. Self-induced vomiting is the most common method of purging although some sufferers abuse laxatives or compensate for overeating with excessive exercise. The purging behavior is used to prevent weight gain following a binge.

Patients with bulimia often have a normal body weight and appear healthy. They can be fully functional, attending school or working and having what appears to be a good life. A person with bulimia may feel that she is overweight regardless of her actual weight. Her body shape and weight are often the main measure of how she feels about herself and her self-esteem.

Causes of Bulimia Nervosa
The exact causes of bulimia are extremely difficult to identify as they are a complex web of psychological, social, and biological factors that are unique to each sufferer. So cial attitudes towards body size and appearance likely contribute to the illness. Patients with bulimia may have a history of sexual or physical abuse, drug abuse, anxiety disorders, low self-esteem, perfectionism or excessive peer pressure. Binge eating may be triggered by low mood, depression, stress, hunger following dieting and anxiety. The individual uses food to reduce these negative feelings but the binge is often followed by worsening self-blame, self-hatred and depression. Suicide attempts are common and 4% of those diagnosed with bulimia will die as a result of the eating disorder. Eating disorders have the highest mortality rate of any mental illness.

Some Statistics
The majority of patients suffering with bulimia are female (approximately 90% of cases) but many males are affected as well (approximately 10% of cases). According to Statistics Canada, 2015, 1-3% of adolescent women will develop bulimia in their lifetime. The illness typically begins in the teenage years or early adulthood and can be chronic or intermittent, often continuing for a lifetime unless well treated. It is very common in dancers, models, competitive athletes and those who aspire to a perfect appearance. The National Association for Anorexia Nervosa and Associated Disorders (ANAD) states that eating disorders affect all races and ethnic groups. More than half of patients with bulimia have a mood or anxiety disorder and one in ten have a substance abuse disorder, often alcohol.

Exposing the Secret of Bulimia
Dental Professionals can be the first line of defense in identifying the warning signs and symptoms of bulimia.
Because there is an unbelievable amount of shame and embarrassment associated with the disorder, patients will try to keep it a secret from people in their lives.
As a result, the eating disorder can go undiagnosed for many years. There are very few objective findings that would alert a medical professional to the presence of this disorder but bulimia needs to be recognized early because it can be life threatening. Dental professionals have an advantage over medical doctors in diagnosing the disease by observing oral changes.

Changes in the Oral Cavity and Dentition
Changes in the dentition are characteristic of bulimia and in the beginning stage are similar to the oral changes with acid reflux. General chalkiness of the enamel, loss of lustre, decay, sensitivity and erosion are some of the first signs that can indicate bulimia. Over time, generalized erosion of the enamel, starting along the lingual surfaces of the incisors and the occlusal surfaces of the molars will become more and more severe due to the teeth being bathed in stomach acid from vomiting. There can also be damage and redness to the gingiva, tongue, cheeks and the throat. We have all seen the pictures of severe cases of bulimia with restorations standing higher than the teeth and complete loss of enamel – of course these pictures are showing the long term, untreated effects of the disease.

Signs of Bulimia (especially in teenagers and young adults)

  • Tooth decay. A sudden increase in the number and size of cavities can be a red flag.
  • Tooth sensitivity. Erosion of the tooth enamel can lead to dramatic sensitivities.
  • Discolouration and yellowing of the teeth. Initially there is a chalkiness to the teeth, they lose their lustre and can become more stained. With more time, the teeth look more yellow as the protective enamel is lost.
  • Dry mouth and swollen cheeks. This can result from repetitive purging leading to inflammation and problems with the salivary glands.
  • Bad breath. The stomach acid and bile in the mouth creates halitosis. Patients may have bad breath regardless of their efforts with brushing and using mouthwash.
  • Sores on the hands or knuckles. There may be scars on the top surface of the hands from contact with the teeth while pushing their fingers down their throat to cause vomiting. This can be a sign of frequent purging and can help to confirm that an eating disorder may be present.

How You Can Help
Early intervention makes a big difference! By observing signs that suggest bulimia and informing your patient of what you see, you can help to eliminate the secrecy involved and help the patient get necessary treatment.

Talking to a patient about eating disorders can be difficult and must be done in a careful, thoughtful manner that does not blame the patient. Instead, the discussion will be most effective if it conveys concern for the patient’s overall well-being. You may be the first person to know that a problem exists. Some patients affected can be young and even their parents may be unaware of the problem.

Many patients with bulimia will not understand the damage their illness is causing to their body and their health. By educating them on the long-term effects of enamel erosion on their oral health, dental professionals can provide important eye-opening information to help them realize the importance of reaching out for help.

A patient recently interviewed at the Spark Institute where we work extensively with patients with eating disorders, reported that even though she has suffered from bulimia for decades, no medical or dental professional had ever mentioned noticing any symptoms of it. She had lived with her illness in secrecy and only as a mature adult was seeking treatment. Dental professionals need to be aware of how to help these patients and be especially vigilant to the changes in the dentition in young patients.

What to Say to a Patient who has Signs of Bulimia
Because of the shame and secrecy experienced by patients with bulimia, the method for opening this conversation is important. Here is a suggested plan shared by Dr. Natalie Mulligan, ND, a practitioner at the Spark Institute who specializes in the treatment of eating disorders.
1) Clearly describe your findings to your patient (eg. erosion of enamel beyond what would be considered normal for their age)
2) Explain the possible causes of these findings (eg. excessive amounts of sugar, carbonated beverages, citrus fruits, acid reflux or excessive vomiting)
3) Reemphasize the importance of protecting tooth enamel for long term oral health and the irreversible dental complications of the problem
4) Explain that there are resources and treatments available for all of these issues.
5) Have information available that the patient can access privately for eating disorders. Realize that it is unlikely that a patient would admit to being bulimic and that it is best not to use labels such as “eating disorder” or “bulimia” in your discussion.

How to Proceed
If the patient is not receptive to your concerns, it may be best to refer her to her doctor to deal with the issues causing the changes in the mouth. The patient may feel more comfortable discussing her medical and psychiatric issues with her medical doctor.

If the patient is very receptive to your information and questions, you may want to ask more directed questions regarding vomiting and the patient’s understanding of the issues you have noticed. A referral to an eating disorder treatment program would be the ultimate goal.

With young patients, it is important to alert the parents to the problems you detect and the possible causes. A referral to the family doctor (along with a phone call) may be the best way to proceed. Watching for continuing changes in the teeth over future visits would be very important to ensure that the bulimia was being treated effectively.

Tips About Eating Disorders for Parents

  • It is important to realize that eating disorders are often a sign of a mental health issue that needs to be treated. Avoid focusing on food or eating habits only.
  • Forcing someone to change their eating habits or trick them into changing is not an effective strategy.
  • Avoid reacting to a loved one’s body image talk or trying to reason with statements that seem unrealistic to you.
  • Seek support for yourself and your family to deal with bulimia.

Immediate Dental Suggestions for Patients with Bulimia

  • Immediately after vomiting, rinse your mouth with a teaspoon of baking soda mixed into a cup of water to neutralize the acid.
  • Brushing after vomiting will remove softened enamel so patients should wait at least an hour or more to brush. Use a manual, soft bristled brush only.
  • Use a baking soda toothpaste with fluoride. Rub a dab over your teeth with your finger and then rinse with water several times a day.
  • Rinse with a fluoride mouthwash or use a fluoride gel daily (consider custom made trays).
  • Avoid eating acidic and sugary foods- drink pop or fruit juice sparingly or use a straw.
  • Use a tongue cleaner to help remove trapped acid that remain in the papillae and can continue to bathe the lingual tooth surfaces for long periods of time.
  • Drinking water throughout the day can help to flush acidic residue from the oral tissues. Drinking Alkaline water can help to neutralize the pepsin that may irritate tissues.
  • Have regular dental checkups, X-rays and cleanings.
  • Consider a nightguard to protect teeth from further wear due to bruxism.

Realize that none of these recommendations will work and advanced restorative treatments will fail without effective treatment of bulimia.

Treatment of Bulimia
A multidisciplinary approach, either outpatient or inpatient, works best to treat bulimia. A combination of individual therapy, family therapy, behaviour modification, nutritional rehabilitation as well as lifestyle changes to manage stress and anxiety are all necessary for long term health.

As an example, at the Spark Institute in Vaughan, Ontario, patients are seen on an outpatient basis. They have between one and seven appointments a week- these include psychological counselling, family counselling, medical appointments, nutrition counselling, lifestyle advice, stress management techniques, meal planning and food preparation advice.

It would be helpful to know of some good resources in your area for your patients to consider.

I hope this article has alerted you to another way you can make a big difference in someone’s life. There is no doubt, with the number of patients suffering with bulimia, a few of them are being treated in your practice each month. By using some of the suggestions made in this article, you can help them to get the treatment they need to recover from their illness, improve their health and save their teeth as well!

1. Canadian Mental Health Association website: http://www.cmha.ca/mental_health/facts-about-eating-disorders/#.V-wxNfArLIU
2. Statistics Canada: http://www.statcan.gc.ca/pub/82-619-m/2012004/sections/sectiond-eng.htm #a2, 2015
3. ANAD: https://studyclerk.com/blog/eating-disorders
4. Restoring Our Bodies, Reclaiming our Lives; Amy Liu, Trumpeter Books, Boston, 2011
5. The Spark Institute Website: http://thesparkinstitute.com/
6. http://www.dentistryiq.com/articles/2010/06/dental-professioinals-can-be-the-first-line-of-defense-in-eating-disorder-diagnosis.html
7. http://www.rdhmag.com/articles/print/volume-31/issue-1/columns/bulimia-decreasing-the-damage-to-enamel.html

About the Author
Dr. Gloria Alban graduated from the University of Toronto, Faculty of Dentistry in 1978. She worked in her own dental practice in Toronto until 2001 when she retired due to health issues. As part of her healing, she became a Holistic Nutritionist in 2010. Dr Alban now works in association with the Spark Institute in Vaughan, Ontario – an integrative clinic devoted to preventive medicine and the treatment of anxiety, depression, eating disorders and digestive disorders. She may be contacted at info@thesparkinstitute.com.