Medical History
Patient was diagnosed with anxiety disorder in high school, and is taking 20 mg of duloxetine hydrochloride (Cymbalta) twice daily. The patient is currently under the care of a physician for her medications. She does not have any other significant medical history findings.
Social History
Patient reports that she has a habit of biting her nails. Patient also reports drinking socially with her college friends, as well as frequently eating at fast‐food restaurants. She has a membership to the college fitness facility, and frequents it often because she feels that she is overweight. She states that she goes through phases of uncontrollable binge eating and reports vomiting on occasion or uses laxatives after the binges. Patient reports only drinking bottled water and carbonated soft drinks.
Since she has been away in college, the patient reports that she hasn’t visited her dentist in over a year. Her daily home care consists of brushing once a day in the morning. She reports flossing occasionally and uses a generic‐brand mouth rinse on a daily basis, but cannot recall the name of the mouth rinse and what it contains.
Review of Systems
- Blood pressure: 110/65 mmHg
- Pulse rate: 60 beats/min
- Respiration: 17 breaths/min
Extraoral Examination
Nail biting is evident. There is evidence of ecchymosis and calluses on the back and knuckle area of the patient’s right hand. Patient also presents with dry, cracked lips. There is bilateral swelling of the zygomatic facial regions.
Intraoral Examination
- Lingual surface erosion of #s 7–10, appearing translucent and glasslike, especially on the incisal edges of the teeth with slight chipping.
- Generalized interproximal caries
- Bilateral swollen parotid glands
- Hyposalivation
- Inflamed and erythematous pharyngeal tonsillar area
Intraoral Pictures
Figure 9.2.1 and Figure 9.2.2 provide images in palatal view.
Figure 9.2.1: Maxillary incisors palatal view 01.
Figure 9.2.2: Maxillary incisors palatal view 02.
Dental Hygiene Diagnosis
Table 9.2.1 gives details of the diagnosis.
Table 9.2.1: Dental hygiene diagnosis.
| Problems | Related to risks and etiology |
| Increased caries risk | Xerostomia and hyposalivation Dehydration Poor oral hygiene: brushing once a day and occasional flossing Infrequent dental visits High carbohydrate diet |
| Lingual erosion of maxillary incisors | Perimylolysis |
| Chipping of maxillary incisors, #s 7 and 8 | Nail biting and perimylolysis |
| Increased hypersensitivity | Chemical erosion |
Planned Interventions
Table 9.2.2 gives details of the interventions planned for this patient.
Table 9.2.2: Planned interventions.
| Clinical | Education/counseling | Oral hygiene instructions |
| Radiographic examination Adult prophylaxis In‐office fluoride treatment using fluoride varnish containing 5% neutral sodium fluoride Refer to DDS for planned caries restorations and aesthetic maxillary anterior teeth fixed prosthodontic restorations Three to four month recare schedule to monitor new incidence of caries and erosion |
Avoidance of brushing immediately after vomiting Sugar‐free mints or xylitol gum to promote salivary flow Increase intake of fluoridated water Encourage increased compliance to specialist visits for psychiatric counseling Nutritional counseling |
Nonalcoholic fluoridated mouth rinse Lubricating mouth rinse for xerostomia Brushing twice daily with extra‐soft toothbrush using fluoridated toothpaste Daily interdental care |
Discussion
In the psychiatric literature, bulimia nervosa, and anorexia nervosa are interconnected by the term eating disorder (Pantzari et al. 2015). Of the patients suffering from bulimia nervosa 80% are female, and in that 80%, 1–2% are adolescents and young adult women (National Eating Disorders Association 2016). Bulimia nervosa presents as a psychiatric compulsive disorder, and is frequently linked to depression and changes in social adjustment (National Eating Disorders Association 2016). Risk of death from suicide or medical complications is significantly increased for eating disorders (National Eating Disorders Association 2016).
Bulimia nervosa has two defined types: nonpurging and purging. In the nonpurging type, the patient can engage in inappropriate behaviors, such as excessive exercise and fasting but does not involve the usage of laxatives and vomiting behaviors. In the purging type, the patient frequently engages in self‐induced vomiting, usage of diuretics, enemas, or overuse of laxatives (Boyd and Wilkins 2016). The profile of the bulimic patient can include: normal body weight and/or slightly overweight, severe dehydration, and electrolyte imbalance from excessive purging, swollen salivary glands especially in the parotid region, with a commonly swollen and inflamed throat. Teeth can also show signs of chemical erosion, sensitivity, and increased caries (Lasater and Mehler 2001). These eating disorder characteristics/profiles can lead to a pathological control of body weight, and can cause systemic and oral alterations (Schlueter et al. 2012).
Patients with eating disorders are typically treated with antidepressant medications that can result in xerostomia or hyposalivation (Hunter and Wilson 1995; Sreebny and Schwartz 1997). It should be noted that a dry oral cavity, coupled with poor home care, may enhance dental plaque accumulation on teeth surfaces facilitating cariogenic bacterial growth on fermentable carbohydrates (Romanos et al. 2012).
Developing erosive lesions on teeth and dental wear is a notable finding of eating disorder patients, especially with bulimia nervosa, and early diagnosis is essential. In literature, the erosive lesion typically seen in these patients is called perimylolysis (Boyd and Wilkins, 2016). Perimylolysis is defined as a chemical erosion by acid to the tooth surface, typically from regurgitation of stomach contents (Boyd and Wilkins 2016). It most frequently affects the lingual surfaces of the maxillary anterior teeth. The tongue protects the mandibular teeth from the erosive effects of vomiting (Spear 2008). The maxillary anterior teeth lingual surfaces appear glasslike and translucent, and can become sensitive to thermal changes (Boyd and Wilkins 2016).
For patients, it is difficult to detect early enamel erosion due to its smooth and shiny appearance, and lack of symptoms. It is the responsibility of the dental professional to identify early stages of enamel erosion and implement preventive treatment measures (Baheti and Toshniwal 2015). Treatment should begin with identifying the underlying medical disorder and level of disease progression (Baheti and Toshniwal 2015). Supportive referrals to appropriate specialists are necessary to address the medical well‐being of the patient (Romanos et al. 2012).
Dental hygienists are often the first health‐care professionals to recognize signs of chemical erosion of the teeth. Dental hygienists are able to provide preventive measures to minimize the effects of chemical erosion, and make necessary referrals for caries restoration. Preventive measures can include: caries risk assessment, application of fluoride varnish, and nutritional counseling with dietary analysis. Preventive measures that can be employed by the patient should include: avoidance of toothbrushing after regurgitation, use of a low‐abrasive fluoridated toothpaste, and salivary stimulation by using sugarless candies or gum (Baheti and Toshniwal 2015).
Depending on the degree of tooth wear, restorative options can range from localized composite restorations to prosthodontic reconstruction of the affected teeth (Baheti and Toshniwal 2015). A three to four month recare schedule is recommended to maintain patient compliance, and to monitor/assess new incidence of caries and erosion.
Take‐Home Hints
- Females are at higher risk of developing bulimia nervosa than males.
- Early detection of dental erosion can be indicators of an underlying feeding/eating disorder.
- Vomiting associated with a feeding/eating disorder can be related to dehydration, xerostomia, and perimylolysis.
- Teeth surfaces most affected by vomiting are maxillary anterior lingual surfaces.
- Identification of early dental erosion by the dental professional is important in identifying an underlying medical condition that can be detrimental to the patient’s health.
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