6-18: Acid Tooth Erosion (Bulimia)

Clinical Summary

Bulimia nervosa is an eating disorder with significant associated physical complications. It is characterized by binge eating with self-induced vomiting, laxative use, dieting, and exercise to prevent weight gain. Patients with bulimia are at risk for damage to the dental enamel and dentin as a result of repeated episodes of vomiting with chronic exposure to regurgitated acidic gastric contents. The lingual dental surfaces are most commonly affected. In severe cases, all surfaces of the teeth may be affected. Trauma to the oral and esophageal mucosa may also result from induced vomiting. The quantity, buffering capacity, and pH of both the resting and stimulated saliva are found to be reduced, and salivary gland enlargement, most commonly the parotid, may occur as well.

Included in the differential diagnosis of acid tooth erosion are conditions that involve recurrent vomiting. Xerostomia is a condition of excessive mouth dryness (associated with Sjögren syndrome) that can also accelerate the process of enamel loss. Tooth abrasions and erosions may be brought about by the use of chewing tobacco, eating betel nuts (Indian paan), dentifrice use, bruxism, abnormal swallowing, and jaw clenching.

Management and Disposition

The initial emergency department management of patients with bulimia should address any medical complication of the disorder (eg, hypokalemia, metabolic acidosis). Hospitalization to stabilize medical complications and provide nutritional support may be indicated. Dental treatment should begin with vigorous oral hygiene to prevent further destruction of tooth structures. Regular professional fluoride treatments to cover exposed dentin and cosmetic procedures should be instituted once the patient is adequately stabilized psychologically. A multidisciplinary team approach is necessary and should involve psychiatry, internal medicine, and dental consultation as needed.

Pearls

1. The lingual surfaces of the teeth are the most commonly involved tooth surfaces.

2. Bruxism tends to cause enamel loss from occlusal and incisal dental surfaces.

3. The labial and buccal surfaces of the teeth tend to show enamel loss from repeat or prolonged chemical contact (eg, lemon sucking or tobacco products).