OBSERVATIONS GORDON J. CHRISTENSEN, D.D.S., M.S.D., Ph.D.

Oral care for patients with bulimia

t is well-known that many females and a few males suffer from bulimia, also called the binge-purge syndrome. These patients are easy to identify when they visit the dentist for oral therapy. People who have engaged in bulimic activity for a moderate period of time (from months to a few years) have severe erosion on the lingual surfaces of the maxillary anterior teeth. The lingual and occlusal surfaces of the upper molars have moderate erosion, and the lower posterior teeth may have erosion on their lingual and occlusal surfaces. The person may have a normal overall body appearance. However, observable tooth erosion is a major sign of the bulimic behavior. As bulimia continues for longer periods, the teeth have generalized erosion, an unsightly appearance and moderate-to-severe sensitivity. Differential diagnosis for other conditions includes gastroesophageal reflux disease, excessive use of or peculiar habits with acidic foods and numerous less common conditions. However, the characteristic dental signs of bulimia are quite recognizable. The dentist should describe the patients condition to her or him and should ask the patient if there is anything she or he

might be doing that could be related to the dental damage. A few bulimics will admit their activities, but the majority will not admit that they frequently regurgitate. If the person is a child or an adolescent, the dentist should contact her or his parents privately and ask them to observe the patients behavior. Some of the indications of bulimia are Observable tooth erosion is a major sign of bulimic behavior. As bulimia continues for longer periods, the teeth have generalized erosion, an unsightly appearance and moderateto-severe sensitivity.

leaving the dinner table immediately after eating to go to the restroom; noticeable excessive use of spoons or other eating utensils (used to initiate vomiting); odor of vomit in restrooms or outside in the yard; an irritated area or callus on the top surface of the right (or, less frequently, the left) forefinger, caused by rubbing the finger on the incisal edges of the upper anterior teeth while inducing vomiting; or eating great quanti-

ties of food without the expected weight gain. Parents easily can detect the characteristic conditions relating to bulimic behavior. Using great tact and providing sufficient patient education, the dentist should refer the patient to a qualified eatingdisorder clinic. Such facilities are available in most areas of the country. If the person suspected of having bulimia is an adult, the dentist should offer her or him the opportunity to visit an eating-disorder clinic. Dentists should use caution in confronting patients about bulimia, and suggestions about going to an eating-disorder clinic should be offered on the basis that a visit would eliminate the possibility of an eating disorders being the cause of the oral problem. Assuming the patient now is in competent hands for the potential eating disorder, what should be done for the dental condition?
TREATMENT FOR TEETH WITH MODERATE DESTRUCTION CAUSED BY BULIMIA

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Dental damage related to moderate bulimia is located mainly on the lingual surfaces of the upper anterior teeth. The esthetic appearance of the upper
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JADA, Vol. 133, December 2002 Copyright 2002 American Dental Association. All rights reserved.

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anterior teeth is acceptable in cases of slight-to-moderate damage. However, the anterior teeth extrude as the enamel is eroded, and the lower anterior teeth and the upper anterior teeth have contact in centric occlusion. Often, the lingual surfaces of the upper anterior teeth become sensitive. Usually, the lower anterior teeth have not had significant damage because of salivary flow and tongue movements. The following technique satisfies the patients needs for an interim period: 1. Anesthetize the involved upper anterior teeth. The eroded teeth usually are canines and lateral and central incisors. 2. Since most of the enamel is eroded from the lingual surfaces of the teeth, a layer of resinbased composite is needed to cover these surfaces. Because the anterior teeth have extruded and are in occlusion, there is no space for the resin. The vertical dimension of occlusion must be opened. Place numerous small 14 round bur retentive features in the lingual dentin all around the periphery of the eroded area in a pattern near the juncture of the dentin and the remaining eroded enamel. 3. Start the restoration of the anterior segment with a maxillary central incisor if possible. After roughing the enamel and dentin surfaces of the affected area with a coarse diamond rotary instrument, place strips of polyester film (Mylar, DuPont Teijin Films U.S. Limited Partnership, Wilmington, Del.) between the tooth being restored and the adjacent teeth. Use a self-etching primer bonding agent on all of the lingual dentin and enamel of the one tooth, using care to get the solution into the retentive holes.
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Self-etching primers are preferred over total etchants because of the greater possibility of reduced postoperative tooth sensitivity with self-etching primers. A current popular product is Clearfil SE Bond (Kuraray America Inc., New York). 4. Place the resin-based composite of your choice on the lingual surface of the one affected tooth and cure the resin. Lowwear microfill composite is preferred (one example is Heliomolar, Ivoclar/Vivadent, Amherst, N.Y.). 5. Evaluate the occlusal Patients with severe tooth erosion have characteristics that may resemble the destruction caused by any of the conditions responsible for tooth erosion.

opening. Make sure there is space to place a layer of composite on the other teeth to be restored. Finish the composite on the built-up tooth. The opening of vertical occlusion should be about 1 millimeter. 6. Repeat the resin-based composite placement procedure on the other teeth, carefully closing the upper and lower teeth together to the level of the first restoration before curing each subsequent restoration. If the lingual surfaces of the upper molars are eroded as well, place a protective coating of resinbased composite on their lingual surfaces at this time. 7. Finish and polish all of the restorations while adjusting occlusion carefully on the anterior teeth. Establish adequate

incisal guidance and a moderate canine rise. Important note: The posterior teeth are now out of occlusion up to 1 millimeter. 8. Advise the patient that her or his posterior teeth will not be in contact for a few weeks. The posterior teeth of a typical adolescent will extrude in a few weeks to a few months. After accomplishing this procedure on many patients, I have not seen any of them experience any long-term discomfort related to allowing the posterior teeth to extrude. 9. Place the patient on a regimen of high-concentration fluoride in trays to reduce the tooth sensitivity and the chance of additional caries. Colgate PreviDent (Colgate Oral Pharmaceuticals Inc., Canton, Mass.) is one such fluoride product. 10. Have the patient come back to the office for several evaluations over the next few weeks until all of the teeth are in occlusion. 11. Continue to consult with the eating-disorder clinic about the progress of your shared patient. This therapy for a patient with slight-to-moderate bulimia is effective and will serve for several years, depending on the degree of cure of the bulimic condition. Assuming that the bulimia is controlled, the most affected teeth should receive crowns.
TREATMENT FOR TEETH WITH SEVERE EROSION CAUSED BY BULIMIA

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Patients with severe tooth erosion have characteristics that may resemble the destruction caused by any of the conditions responsible for tooth erosion. In other words, diagnosis of the cause of erosion is more difficult

JADA, Vol. 133, December 2002 Copyright 2002 American Dental Association. All rights reserved.

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in extreme cases. The cause of the continuing tooth erosion should be investigated, and referrals to appropriate health professionals should be made to assist in eliminating the cause of the tooth destruction. Patients with severe erosion may have a closed vertical dimension of occlusion, tooth sensitivity, a poor esthetic appearance and lowered selfesteem because of the appearance of their smile. If the cause of the erosion has been identified, and treatment of the cause is considered to be effective, the patient has only four oral alternatives: dLeave the teeth in their current condition until one of the following treatments is mandatory. dMake a maxillary polymer occlusal splint similar to those used for temporomandibular joint dysfunction, opening vertical dimension of occlusion and placing resin-based composite teeth in any area where needed. Polymer teeth placed on the

splint offer an acceptable esthetic appearance, and they support the opening of vertical dimension of occlusion. The relative low wear resistance of the acrylic resin reduces subsequent wear of the opposing natural lower teeth. Fluoride gel should be placed in the splint each day to avoid dental caries formation underneath the splint. dPlace crowns on all affected teeth, opening vertical dimension of occlusion and restoring adequate function and esthetics. dRemove the teeth and fabricate removable complete dentures. There are no intermediate treatments for extremely eroded teeth. Depending on the patients desires and financial considerations, any of the described therapies will be successful for different periods.
SUMMARY

drome. Dentists frequently encounter patients who have this problem. The Dr. Christensen is codentist should founder and senior confirm the pos- consultant of Clinical Research Associates, sibility of 3707 N. Canyon Road, Suite No. 3D, Provo, bulimia, refer Utah 84604, and is a the patient to a member of JADAs editorial board. He has a competent masters degree in eating-disorder restorative dentistry and a doctorate in educlinic, counsel cation and psychology. the patient He is board-certified in about her or his prosthodontics. Address reprint requests condition and to Dr. Christensen. restore the patients mouth to a state of health and esthetic acceptability. Dental treatment of such patients will vary depending on the severity of the erosion. !
The views expressed are those of the author and do not necessarily reflect the opinions or official policies of the American Dental Association. Educational information on topics discussed by Dr. Christensen in this article is available through Practical Clinical Courses and can be obtained by calling 1-800-223-6569.

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Various conditions cause rapid and debilitating erosion of teeth. One of the most common is bulimia, or the binge-purge syn-

JADA, Vol. 133, December 2002 Copyright 2002 American Dental Association. All rights reserved.

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