Millions of people in this country, more than 90% of them young women, suffer from serious eating disorders such as anorexia nervosa and bulimia. These disorders wreak havoc not only on a patient’s psyche and physical health, but also upon the teeth and mouth. Additionally, eating disorders are often difficult to identify, hard to treat, and have a high relapse rate, further contributing to poor dental health. As the earliest symptoms of an eating disorder manifest themselves orally, it is imperative that dentists be aware of these symptoms and be knowledgeable about how to treat the disease’s effects.
Eating disorders can result in a variety of problems requiring different methods of treatment to restore patients’ smiles to their former beauty. The clinician must assess the entire situation, including tooth loss and erosion, gingival inflammation and damage, discoloration, and bite displacement. Once a patient has recovered from the physiological and psychological effects of anorexia or bulimia, the clinician can determine the best individual course of treatment using various technologies to address specific aesthetic and functional problems.
Oral manifestations of an eating disorder include the following: erosion of tooth enamel; halitosis; increased caries; sore throat; oral sores; dentinal sensitivity; swelling of the parotid, sublingual, and submandibular salivary glands; and xerostomia. Patients often exhibit abrasions on their fingers and hands from self-induced vomiting. The lingual aspect of the upper anterior teeth is often damaged due to purging, and in the most severe cases erosion can extend to the occlusal surfaces of the posterior teeth and the facial surfaces of the maxillary and mandibular teeth.
Bulimics commonly exhibit front teeth that are smooth, glassy, and unstained. After 2 years or more of repeated purging, the erosion spreads to the back teeth, causing a loss of biting surface, decay, and pulpal involvement. These patientsí teeth traditionally demonstrate great sensitivity to temperature, a raised appearance to fillings, and a change in bite due to eroding tooth structure. The gingival tissue is also affected by the trauma of forced vomiting and the accompanying dehydration.
A dental professional may be the first healthcare provider to become aware of a patientís eating disorder by finding a pattern of erosion and decay consistent with the symptoms described above. Thus, it is imperative that dentists, especially those treating young patients, be aware of the indications of these diseases and also be knowledgeable about medical and therapeutic support facilities in the community to which the patient and his or her family may be referred.
DENTAL TREATMENT
Dental restoration should be commenced only after successful treatment of the eating disorder. Dental professionals should recommend various treatments during this stage in order to prevent further erosion of the teeth, such as regular cleanings, fluoride treatments, and desensitizing toothpaste. Some dentists do utilize the conservative placement of plastic restorative materials or adhesive refurbishment to prevent further deterioration until the patient has fully recovered.
Patients should be advised that brushing teeth immediately after vomiting can actually lead to excessive decay. Most importantly, the dentist should refer the patient to a mental health professional who specializes in eating disorders. Relapse is common with eating disorders, and patients should have regained their lost weight and show adequate long-term stabilization before dental restoration begins. Only when the patient has made a significant improvement both physically and mentally should restorative procedures begin to help the patientís mouth regain its function and attractive appearance.
The following case report involves comprehensive dental treatment of a patient who had suffered for years from a combination of eating disorders.
CASE REPORT
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Figure 1. Patient’s preoperative condition. |
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| Figure 2. Bite-opening orthotic. |
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Figure 3. Processed acrylic temporary restorations at restored vertical dimension. |
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Figure 4. Final crown restorations and restored aesthetic smile. |
A female patient presented to my office after having been both anorexic and bulimic for several years since age 15. She had received psychological counseling and she had great parental support; she had been free of the disease for a full year before we commenced dental treatment.
The patient presented with the after-effects of bulimia. There was considerable loss of the natural enamel, rampant decay, and several millimeters of lost vertical dimension (Figure 1). Her oral hygiene was good, with little calculus or plaque and no gingival inflammation or bleeding.
All of the maxillary teeth and mandibular posterior teeth were affected; 50% of each tooth was worn away. She was an example of someone who had suffered from an extreme case of the eating disorder because the damage had spread so extensively to her posterior teeth. Her bite had collapsed because of the extent of the erosion. The lower front teeth remained intact because the tongue protected them, but root canal therapy was performed because deep decay was present that left the teeth without adequate tooth structure.
After extensive consultations with the patient and her parents, treatment began with excavation of the decay throughout her mouth. Intermediate Restorative Material (IRM [DENTSPLY Caulk]) was used to fill all of the cavities temporarily, and referral to an endodontist was initiated to treat pulpal exposure.
Interocclusal bite registrations were obtained using baseplate wax at the correct vertical dimension. The casts were mounted on a Whip Mix 2000 series articulator, and a bite-opening orthotic was fabricated (Figure 2). This appliance was worn 24 hours a day, 7 days a week.
The next step was the construction of a hard-tissue crown-lengthening splint and referral to a periodontist to complete the necessary crown-lengthening procedure. The patient continued for 3 months following the periodontal surgical procedures until she was ready to proceed with prosthetic reconstruction. Mounted casts were prepared for processed acrylic temporaries, which restored the lost vertical dimension at the correct position, determined through the use of the bite-opening orthotic.
All teeth were prepared for full-coverage crowns, polyether (Impregum [3M ESPE]) impressions were obtained, and the processed acrylic temporaries were fitted (Figure 3). Standard prosthodontic procedures were followed through fitting, bisque tryin, temporary cementation, and final cementation.
The final restoration consisted of 16 porcelain-fused-to-gold crowns on the posterior teeth and 12 all-ceramic (In-Ceram [Vident]) crowns on the anterior teeth (Figure 4). All restorations were bonded in place using full bonding protocol and dual-cure resin cement (Calibra [DENTSPLY Caulk]).
This patient is now a woman who speaks and smiles to people up close every day. She is a successful teacher, recently married, and a confident and vivacious young woman with a beautiful smile!
CONCLUSION
The use of prosthodontic treatment to give this woman back her smile is an example of the widening need for this type of treatment. With the aging of the baby-boom generation, there is a growing need for restorative experts. Sadly, the proliferation of conditions such as eating disorders and drug addictions, which cause such extensive damage to teeth, has created a similar need for prosthodontic treatment amongst the younger generations as well.
Dr. Hilsen received his undergraduate training at Rutgers University and his DDS from New York University. He was awarded the Certificate of Specialization in Prosthodontics from New York University College of Dentistry Division of Post Graduate Education; his internship and prosthodontic residency were performed at the Veterans Administration Hospital in New York City. Dr. Hilsen holds patents for 3 devices designed to treat sleep disorders. He has served the American College of Prosthodontists (ACP) in a variety of leadership positions, is the founder of the ACP Center for Prosthodontic Education, and is a member of the ADA and the American Academy of Sleep Medicine (of which he is a past president). He is a fellow of the American College of Dentists and the International College of Dentists. The medical director of Ridgewood Dental Associates, he can be reached at (201) 652-2474 or RDANJ@aol.com, or by visiting Ridgewooddental.com.
