Bulimia is a Dental Disease

Written By: Brian McKay, DDS Date: April 9th, 2009. Topic: Eating Disorders.

When I tell my dental colleagues that bulimia nervosa is a dental disease they look at me like I come from a different planet. A dental disease, they ask? Isn’t bulimia one of those eating disorders that were mentioned in dental school? Don’t therapists and counselors deal with bulimia and anorexia? How is it a dental disease?

They are astounded when I tell them that according to the Institute of Scientific Research at least 26% and as much as 28% of ALL bulimia nervosa is first diagnosed by a dentist. That usually gets their interest and piques their professional curiosity.

It rocks them when I tell them that number is too low. It should be above 50%!
Why is that? It’s because the mouth does not lie. It cannot hide the truth about bulimia from a dentist. The telltale signs are everywhere. Very distinctive, very dramatic and very evident loss of tooth enamel on the backs of the front teeth is a giveaway to any dentist with eyes. Swollen, red salivary glands usually accompany the missing enamel. Periodontal gum disease is likely present and there could be a number of missing teeth in the most severe cases. It all adds up to one diagnosis: bulimia nervosa. Nothing else in the mouth has that pathology. When you add in the social and psychological factors: age, gender, over-achieving nature, self-esteem problems, environmental issues, temperament – the patient in our dental chair is speaking volumes without having to say a word.

Her name was Megan. She was 26 years old when we met. She weighed a mere 71 lbs. at that time. She had been both anorexic and bulimic since the age of 12. Her life was tragic. She lived in a waking nightmare 24/365. Bingeing and purging consumed her when she wasn’t starving herself. The diseases controlled every action, every thought, every dream and every waking moment. She was imprisoned by the stark reality of trying to live with a terrible eating disorder. It had begun to consume the very tissues of her body. Bone began to resorb, her teeth became loose and fell out as the protective, encasing bone around them shrunk and became brittle. Her body was starved for nutrients as she vomited throughout the early morning hours to rid herself of what little food she retained. She was in the throes of full-blown bulimia and anorexia. At 26, most people still have all 32 teeth but Megan had only 12 when I met her – six upper and six lower. Her teeth and gums reminded me of someone in their 70’s, someone who had experienced a lifetime of neglect.

Her existence revolved around sleeping a very troubled sleep during the day and consuming massive amounts of food at night to fuel her purging activity. Her daily routine was to lie in bed throughout the day, not eating, restless, tossing and turning, too exhausted to find that deep, comforting sleep we all need to feel better. Megan never felt better during those times.

My good friend and professional colleague, Dr. Greg Jantz from The Center for Counseling and Health Resources in Edmonds, Washington contacted me about treating Megan’s dental problems. Dr. Jantz and I had had frank discussions about how bulimia nervosa attacked the mouth and how carefully one had to approach these fragile victims in order to successfully treat them. She was suffering with a very loose front tooth that was causing her unrelenting pain and she needed to see a dentist immediately. We obliged and arranged to see Megan as soon as possible.

When she arrived two things struck me right away. First, she was in dire need of full mouth reconstruction not just emergency care. Her mouth was in bad shape. It wasn’t just the loose tooth in the front. There were many missing teeth, severe gum disease, bone loss and a few abscesses. Her salivary glands were swollen and red. Bulimia had ravaged her mouth almost to the point of total loss. Secondly, this waif of a woman had volumes of character and strength deep within her that were untapped. Her spirit shone through the trauma she was experiencing as she looked me right in the eye and said, “I want to get better – I want you to help me.” My heart broke into a thousand million pieces. Her very presence impressed my entire office staff and me. She was a fighter and had been fighting alone for so long. It touched me far beyond my professional veneer and I was moved emotionally. In my entire career of over 20 years as a dentist, that had never happened before. I knew she was special. I knew I had to help her. My staff felt exactly the same way and came to me after her first visit and told me “whatever it takes, let’s make this girl whole again.”

I had treated many bulimics in my office before Megan. Most had “turned the corner” and were well along the way toward recovery. Their teeth were usually the last thing they addressed in their treatment many telling me that their teeth and smile reminded them of that time in their lives when they were not in control. They were ashamed to smile.

I approach them all in a very non-judgmental way. Too many dentists and their staffs assume a parental role in treating their patients scolding them to brush and floss better. It has been years since I did that with my patients. I found that it just doesn’t work. People feel bad enough about their teeth. Why should I, or my staff wag their finger and admonish the patient about their oral hygiene and the condition of their mouth? It is what it is. And it is our responsibility to fix it.

My success rate with patients soared when I stopped being their parent and became their practitioner. I want to restore their smiles not be their parent. With bulimics and anorexics it is the same only much more intense. They will not return to your practice if you make them feel worse than they already do. It’s as simple as that.

Almost any dentist with advanced cosmetic training is equipped to handle the dental needs of an eating disorder victim, but I am saddened by their inability to deal with the whole person. The reason seems to be that a lot of dentists publicly judge their patient. They are not yet aware of the non-judgmental approach needed to successfully treat and complete the treatment of their patients, let alone someone dealing with a challenge that is so much larger than just their dental needs. Tony Robbins, the noted author and lecturer, taught me the Platinum Rule. It is stronger than the Golden Rule, which states, “Treat others as you would like to be treated.” While the Platinum Rule is “Treat others as they would like to be treated.” Another mentor, Walter Hailey, told me, “The more you know about your patient; the more they think you know about dentistry.” That is the essence of relationship building with patients and the key to working successfully with bulimics and other eating disorder patients. Treating bulimics successfully was the natural next step in my development.

Both Dr. Jantz and I believe that dentistry for bulimics should be included in the standard of care. This may appear to be a radical concept when contemplated for the first time. However there is not an eating disorder treatment specialist practicing today that does not realize that bulimia wrecks the teeth and mouth of bulimics and that restoration improves their self-esteem, makes them feel whole again and finally helps to put their disease behind them. A new smile is a wondrous thing not only to behold but also to own. On a practical level there needs to be a meeting of the minds between the eating disorder treatment specialist world and the dental world. By integrating the two fields, teams can be formed that treat the entire person. From there a standard of care will emerge and a safety net will form around these patients in which all of their fears can be put to rest and we can successfully treat the mind and the body completely and with amazing results.

There are tens of thousands of “Megans” out there and thousands of “Marcs” too. Each is suffering in his or her own way with this terrible disease. Children as young as 9 years old are turning up at treatment centers like Dr. Jantz’s in Edmonds. How does this happen? Is it an indictment of our society? Is it a symptom of something much larger at work? My book examines what bulimia and purging disorders are and illustrates the uncertainty of a professional community that is struggling to catch up with it. It also puts things into perspective for the dental professional. My hope is to enlighten many and motivate a few to take the next step. Learn how to talk to these fragile personalities. Treat them as whole human beings and follow up on their care. It takes years for them to complete their treatment and address the underlying issues that spark the disorder. I am sounding the clarion call to my fellow dentists to become aware, to become advocates of change and to work hand in hand with eating disorder clinics and professionals in turning this preventable situation around. You just need to see the smile within emerge to be convinced that you can be a vital part of the success equation for eating disorder victims.

For the purpose of the online CE Course, the article objectives are:

Inform eating disorder professionals of dentistry’s key role in early detection.
Encourage the eating disorder professional to expand its understandin of the importance of including dental professionals in the treatment process.
Developing programs with trained dentists to motivate eating disorder professionals to include a dentist in the treatment plans and be sensitive to dental health. Keeping DDS informed while making progress with treatment.

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