Eating disorders such as anorexia nervosa, bulimia nervosa, and binge-eating disorder are a serious concern in women’s oral health and a clinical challenge to dental professionals. Each of these eating disorders presents with unique patterns of psychological, medical, and dental characteristics. Appropriate dental treatment is based on the multidisciplinary facets of these conditions. The dental team should be mindful that individuals who suffer from these disorders might relapse into previous negative eating behaviors. The knowledgeable dental professional may be able to intercept these habits through regular recall intervals and a thorough examination.1
From both an ethical and legal standpoint, knowledge of the symptoms and clinical oral signs of bulimia is imperative, since early diagnosis and treatment are directly related to successful therapy.2 Being able to identify bulimia at the outset will help in the timing of selected treatment procedures. Oral surgery, in particular third molar surgery, may pose a significant relapse risk for recovering bulimic patients3 and thus should not be a priority. An eating disorder is many things–deadly, addictive, uncontrollable, and terrifying. Most people have a general knowledge of anorexia and bulimia, but few really understand their complexity.
Bulimia Nervosa is generally considered to be a psychological and emotional disorder, which sometimes co-exists with other psychiatric disorders, such as depression or obsessive-compulsive disorder. In 1980, the American Psychiatric Association formally recognized bulimia. In its fourth edition, the Diagnostic and Statistical Manual of Mental Disorders (APA, 1994) listed the following criteria that an individual must meet to be diagnosed:
A. Recurrent episodes of binge eating, with an episode characterized by (1) eating in a discrete period of time, usually less than two hours, an amount of food that is significantly larger than most people would eat during a similar period of time and under similar circumstances; and, (2) a sense of lack of control over eating during the episode, such as a feeling that one cannot stop eating.
B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or enemas (purging type); or, through fasting or excessive exercise (nonpurging type).
C. These behaviors occur at least twice a week for at least three months.
As a group, patients with eating disorders have a caries rate that is higher than for a similar reference group. More than one-half the subjects in a paper by Ohms et al had erosive tooth wear involving the dentine and about one-third had very low un-stimulated salivary flow rates with very high counts of streptococci mutans and lactobacilli. Erosive tooth wear was significantly related to the number of years of binge eating.4,5 Dental patients with eating disorders need more aggressive preventive programs created in consultation with the health professionals directly involved with their ongoing supportive care.6
All but one of the many eating disorder cases I have been involved in over the last thirty-seven years were female. Tooth erosion varied from mild to extremely severe. This case involved a multidisciplinary approach to therapy.
PROSTHODONTIC TREATMENT APPROACH
The patient presented as a referral in August, 2001, specifically to treat her severely eroded teeth. She was 30-years-old and weighed 110 pounds. In addition to bulimia she suffered from moderate asthma. Ventolin and Flovent twice daily on a regular basis controlled the asthmatic episodes. The rest of her medical-dental history was unremarkable. There was doubt, expressed by her father, a physician, regarding the cessation of bulimic practices.
As is evident in Figures 1-6 there was generalized erosion of the entire dentition. Amalgams in the posterior teeth were 1-2mm above the remaining tooth structure. Clinically these amalgams projected above the enamel and had maintained the vertical dimension of occlusion (VDO).
The dilemma as I saw it was the absence of any usable anterior guidance and the lack of space to create restorations with proper resistance and retention form. Even if the case could be opened up to a new VDO, a protective anterior guidance would not be possible.
The first step was to seek an orthodontic opinion and place the patient in an orthopedic appliance to test a more open VDO. The first wax up (Fig. 7) determined the VDO for this appliance. The patient, however, could not tolerate the new VDO and thus I decided to maintain the present VDO.
During the healing phase of the upper anterior surgery Empress laminate crowns were placed from 43-33 in order to create an ideal incisal plane for the upper anteriors (Fig. 23). The preparation and temporization was facilitated with silicone indices made from the second diagnostic wax up (Figs. 7-12). No posts were placed in the root canal space as there was sufficient tooth core material remaining to create proper resistance and retention form7 (Fig. 13).
ORTHODONTIC TREATMENT PHASE
The goal of orthodontic treatment was to open the bite in the anterior region. Because the prosthodontist wished to maintain the pre-treatment vertical dimension, it was decided to open the bite through intrusion of lower incisors rather than through extrusion of posterior teeth. The excess depth of the curve of Spee was likely the result of over eruption of the lower incisors as tooth erosion had taken place.
Orthodontic brackets were placed on all lower teeth and a light nickel-titanium wire was placed to begin the leveling process. The upper arch was stabilized with a vacu-form retainer. On the second visit, a stainless steel “utility” arch wire was added over the main arch wire to deliver an intrusive force to the lower anterior teeth. The wires were adjusted until there was about 3mm. of bite opening between the upper and lower incisors.
After eleven months of treatment, the brackets were removed and a wire retainer was bonded to the lingual of the lower anterior teeth. A vacu-form retainer was also placed to further stabilize the position of the lower teeth (Figs. 15-22).
ENDODONTIC AND PERIODONTAL PROCEDURES
Endodontic treatment was completed on the upper anteriors from cuspid to cuspid due to sensitivity. Crown lengthening was needed: in order to create a ferrule, for resistance and retention form (no lingual walls) and cosmetic concerns regarding the length of the upper anteriors.
The crown lengthening procedure was completed by a periodontist under neuroleptanalgesia utilizing intravenous diazemuls 10mgm., fentanyl 50mcgm., glycopyrolate 0.2mgm. and propofol as an infusion. Local anaesthesia was achieved with Astracaine 4% 1:200,000 epinephrine by infiltration over the surgical area. A surgical stent, developed from the original wax up, was used for the crown lengthening procedure (Fig. 22).
GENERAL PRACTICE PHASE
Due to the possibility of recurring bulimia, direct bonding was the treatment of choice over bonded porcelain or full crown coverage restorations of her posterior dentition.
Direct bonding is a simple non-invasive procedure that allowed for
1. Replacement of the circumferential eroded enamel;
2. Elimination of dentin sensitivity;
3. Restoration of the teeth to proper form and function;
4. Less cost but proven long-term results.
The patient presented to me with amalgam restorations intact and they were left untouched to provide a reference for the original vertical dimension of occlusion and the exact relationship of the posterior teeth.
Before proceeding I discussed the technique, advantages, disadvantages and limitations of direct bonding and suggested she try without local anaesthesia. She agreed and if the work were too uncomfortable, then I would administer the local. I routinely work utilizing rubber dam but due to the short tooth height and erosive lesions I chose to use cotton roll isolation
Treatment began with a three-hour appointment focused on the restoration of all posterior tee
th on the right side. Between teeth that had extremely tight contacts, a Henry Schein Arcona (USA) needle diamond was used to break the contact and allow for a matrix band to be placed.
Starting with tooth 14, the tooth was banded with a #7 Unitek Matrix Band (California, USA) and held in place with Premier Anatomical Wedges. Etchrite (Pulpdent, USA) was placed first on the enamel and then dentin, left for 15 seconds, rinsed well and left wet. i-Bond (Heraues Kulzer, Germany) was applied as per manufacturer’s instructions and cured with the Spectrum 800 light (Caulk Dentsply, USA). Matrixx Anterior Hybrid (AH) (Discus Dental, USA) Shade B1 was placed in increments less than 2mm, molded to shape with Ausculpt gold instruments and cured for 10 seconds at 300nm. Once the tooth was built up the resin was cured on all surfaces for 10 seconds at 800nm then for 40 seconds at 800nm. Final trimming, and polishing was completed before the next tooth was restored. All premolars were banded with #7 Unitek bands and the molars with #12 bands. Trimming and Finishing burs [7901, 7404, 7906] (SSW, USA) were used for gross reduction and placing simple anatomy. Soflex XT discs (3M /Espe, USA) and finishing strips were used to contour the restoration. Astropol (Ivoclar-Vivadent, Liechtenstein) polishing points and Enamelize paste (Cosmodent, USA) imparted a high gloss and luster to the resins. The occlusion was checked with Accufilm 1 green articulating paper (Parkell, USA) and verified with Shimstock (Almore International, Inc, West Germany) on the contra-lateral side.
I was able to restore teeth 14-17 and 44-47 at this appointment and the patient was seen again eight days later for restoration of teeth 24-27 and 34-37 (Figs 25-28).
The patient was seen in our office for her scaling appointment recently at which time she stated that all sensitivity had resolved, the fillings were comfortable and she was very pleased with the aesthetics. It was noted that 24,25 and the mesio-palatal of 26 had de-bonded and they were restored again using the same technique and materials.
The goals of restoring these teeth were accomplished in an ultraconservative manner until such time when the patient is ready to proceed with indirect ceramic bonded onlays or full crown coverage.
Bruce Glazer practices prosthodontics and anaesthesia and is the prosthodontic consultant to the editorial board of Oral Health.
Peter Gold is a Toronto-based orthodontist.
Wayne Wolfstadt, trained in intravenous conscious sedation, practices full time in Toronto providing general dentistry for physically, emotionally and medically compromised patients.
Thanks to the following laboratories and specialists involved in the completion of this case. Steven Richmond, Gary Glassman, Lionel Lenkinski, Second Nature Dental Laboratory and LHM Dental Laboratory.
Oral Health welcomes this original article.
REFERENCES
1.Eating disorders in women’s oral health. [Review] Dental Clinics of North America. 45(3): 491-511, 2001 Jul.
2.Gross KB., Brough KM., and Randolf PM. Eating Disorders: Anorexia and Bulimia Nervosas. Jour of Dent for Children 1986; 53(5) :378-81.
3.Journal of Oral & Maxillofacial Surgery. 59(11):1297-300; discussion 1300-1, 2001 Nov.
4.Ohrn R., Enzell K., and Angmar-Mansson B. Oral Status of 81 subjects with Eating Disorders. European Journal of Oral Sciences. 1999; 107(3): 157-63.
5.Milosevic A., and Dawson LJ. Salivary Factors in Vomiting Bulimics with and without Pathological Tooth Wear. Caries Research 1996; 30(5): 361-6.
6.Simmons MS., Grayden SK., and Mitchell JE. The Need for Psychiatric-Dental Liaison in the Treatment of Bulimia. American Journal of Psychiatry 1986; 143(6): 783-4.
7.Robbins JW. Restoration of the Endodontically Treated Tooth. Dent Clin N Amer 46 2002;367-384
