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Oral signs and symptoms in the diagnosis of bulimia
CLINICAL
facial region, especially in older adults. O ral pain, paresthesia, and swelling may be the first signs o f the disease. Summary
A rep o rt o f a case o f metastatic renal cell carcinoma to the mandible in a previously asymptomatic person is presented. Metas tatic disease always m ust be considered in any lesion o f the maxillofacial region, es pecially in older adults. Oral pain, pares thesia, and swelling may be the first signs o f disease.
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In fo rm a tio n a b o u t th e m a n u fa c tu re rs o f th e p ro d ucts m e n tio n e d in this article m ay b e available fro m the a u th o rs. N e ith e r th e a u th o rs n o r th e A m erican D ental A ssociation has an y co m m ercial in te re sts in th e p ro d ucts m e n tio n e d . D r. Pick is a s s is ta n t p r o f e s s o r , d e p a r tm e n t o f su rg ery , Case W estern R eserve U niversity School o f M edicine, a n d a tte n d in g o ral a n d m axillofacial s u r g e o n , C le v e la n d M e tr o p o lita n G e n e r a l H o sp ita l, C leveland. D r. W a g n e r is c h ie f re sid en t, d e p a rtm e n t o f o ra l a n d m axillofacial su rg e ry , C leveland M et ro p o lita n G e n eral H o sp ital, C leveland. D r. In d re sa n o is associate p ro fesso r, d e p a r tm e n t o f su rg e ry , Case W estern R eserve U niversity School o f M edicine, an d d ir e c to r , d e p a r t m e n t o f o r a l a n d m a x illo fa c ia l su rg ery , C leveland M etro p o lita n G en eral H ospital, 3395 S c ra n to n R d, C leveland, 4 4 109. A d d re ss re qu ests fo r re p rin ts to D r. In d re sa n o .
REPORTS
1. C lau sen , R., a n d P oulsen, H . M etastatic c a r cinom a to th e jaw s. A cta P ath o l M icro Scand 57:361374, 1963. 2. S h a fe r, W .G.; H in e , M .K.; a n d Levy, B.M . A tex tb o o k o f o ral p a thology, ed 4. P hilad elp h ia, W. B. S a u n d e rs Co, 1983. 3. Sachs, R .L . M etastatic c a rc in o m a to th e ja w bones. T h e sis, N ew Y ork U niversity, 1982. 4. M cD aniel, R .I.; L u n a , M .A.; a n d S tinson, P.G. M etastatic tu m o rs in th e jaw s. O ra l S u rg 31:380-386, 1971. 5. N ish im u ra , Y., a n d o th e rs. M etastatic tu m o rs o f th e m o u th a n d jaws. T O ra l M axillofac S u rg 10:253258, 1982. 6. van d e r K wast, W .A ., a n d van d e r W aal, I. Jaw m etastases. O ra l S u rg 37(6):850-857, 1974. 7. Boles, R., a n d C erny, J . H e a d a n d n eck m etas tases fro m ren al cell carcinom as. Mich M ed 70:616, 1971.
Oral signs and symptoms in the diagnosis of bulimia R ichard A . A bram s, DDS, MPH, MEd J e sle y C. R u ff, DDS
The oral characteristics o f patients with bulim ia are reviewed. Aw areness by the clinician o f these characteristics can fa c ili tate a diagnosis o f bulim ia during routine exam ination.
Description and diagnosis
O n e o f th e m o st p e r p le x in g p ro b le m s a s sociated w ith bulim ia has b e en to establish an a c c u ra te d e fin itio n o f th e en tity . B u lim ia’s m ajor fe atu res a re episodic binge eating ac co m p an ied by a p erce p tio n th a t this p a tte rn o f e atin g is a b n o rm al, fe a r o f b ein g u nable to stop ulimia is an eating disorder that e atin g voluntarily, a n d a d e p ressed m ood and gradually is being discussed in both s e lf- d e p re c a tin g th o u g h ts a f te r th e e a tin g bin g es.716 T h e binges usually a re follow ed by lay and professional circles. T he self-induced vom iting. It is im p o rta n t to d istin disease has a deceptive clinical picture, guish bulim ia fro m a n o rex ia nervosa a n d to and it has been difficult to develop diag ru le o u t o rg a n ic d iso rd e r. A norexia nervosa is nostic criteria to pinpoint w hether a per c h aracterized by a w eight loss o f at least 25% o f son has bulimia. T he American Psychiatric original body w eight. In ra re circum stances, an A s s o c ia tio n 1 a n d i n d e p e n d e n t r e episode o f a n o rex ia nervosa occurs in people
B
searchers2 suggested diagnostic criteria for bulimia and stated that it was an eating d is o r d e r c h a r a c te r iz e d by re p e a te d episodes o f binge eating associated with self-induced vomiting (Fig 1). T he disease has distinct oral consequences in addition to physical an d psychological con se quences.3"5 T he word bulimia literally means ox hunger, indicating voraciousness. O ne of the first recorded instances o f bulimia as a distinct entity is found in the Talm ud, a collection o f Jewish law several thousand years old. T he M ishnah,6 or written por tion o f the T alm ud, speaks o f a person’s being perm itted to eat on Yom K ippur, a traditional holy fasting day, if the person had bulimia.
with bulim ia, in w hich case b oth diagnoses are given.1 In g e n era l, th e e atin g binges a re p lan n e d , a n d usually th e ing ested food is o f an easily swal lo w e d c o n s is te n c y , h ig h in c a lo r ie s , a n d sw eet.9,1117“19 O fte n th e fo o d is e aten rapidly, w ith little c h e w in g , a n d s e c re tiv e ly .9 T h e a m o u n t o f fo o d in g este d d u rin g th e e atin g binge m ay vary, b u t re p o rts o f 3,000 to 6,000 calories seem to b e th e average, with som e re p o r ts o f u p to 2 0 ,0 0 0 c a lo rie s in 1 to 2 h o u rs .18,20,21 A p e rso n w ith bulim ia feels a loss o f co n tro l d u rin g binge e atin g a n d states th a t it is im possible to stop eating. T h e binge con cludes as a re su lt o f abdom inal pain, sleep, so cial in te rru p tio n , o r self-induced vom iting. Al th o u g h ex tre m e ly ra re , sp o n ta n eo u s ru p tu r e o f
■ R ecurrent episodes o f binge eating (rapid consum ption o f a large am ount of food in a discrete period, usually less than 2 hours). ■ At least th ree o f the following: C onsum ption o f high-caloric, easily ingested food d u rin g a binge. Inconspicuous eating d u rin g a binge. Term ination o f such eating episodes by abdom inal pain, sleep, social in terruption, or self-induced vomiting. R epeated attem pts to lose w eight by severely restrictive diets, self-induced vom iting, o r use of cathartics or diuretics. Frequent w eight fluctuations greater than 10 lb due to alternating binges and fasts. ■ Awareness th at the eating p attern is abnorm al and fear o f not being able to stop eating voluntarily. ■ D epressed m ood and self-deprecating thoughts follow ing eating binges. ■ T he bulim ic episodes are not due to anorexia nervosa or any know n physical disorder. Fig 1 ■ D iagnostic criteria fo r bulim ia (adapted from Diagnostic and Statistical M anual o f M ental Dis orders').
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the stom ach has been re la te d to bulim ia.22 T h e self-induced vom iting relieves the abdom inal discom fort a n d Ih e self-d ep recatin g feelings. As a ru le, th e binge itself is pleasurable, b u t the sequelae a re not. P reo ccu p atio n a n d concern w ith th e ir w eight is noticed in p eo p le with bulim ia. T raditionally, a p a tie n t w ith bulim ia has a history o f dieting; vom iting; use o f laxatives, cathartics, o r d iu re tics; o r a com b in atio n o f th e fo reg o in g charac teristics. T h e A m e ric an Psychiatric A ssocia tio n ’s d e fin itio n d oes n o t m an d a te th at a p erso n follow th e b inge e atin g by self-induced vom it ing o r laxatives to have bulim ia, b u t m ost p e r sons w ith bulim ia d o so.9' 11-13,14-23 R ussell18 listed th e follow ing th re e criteria fo r a diagnosis o f “bulim ia nervosa”: p atients e x p e rience p o w e rfu l a n d intractable urges to o ver eat; seek to avoid fa tten in g effects o f food by self-induced vom iting; a n d have a m orbid fe a r o f b ecom ing fat. O nly recently was bulim ia d e fin e d as a dis tinct disease. C a n d o u r9 p o in te d o u t th a t th e re a re su b g ro u p s o f p atien ts h av in g a n o rex ia n e r vosa w ho vom ited a n d binged. A diagnosis o f bulim ia does n o t d e p e n d o n th e p a tie n t’s having lost w eight, a n d o ften th e p ersons with bulim ia a re o f n o rm al w eight o r 5 to 15 lb overw eight.12
Epidemiologic characteristics E atin g d iso rd e rs such as bulim ia m ay be m ore p re v alen t as a re su lt o f increased social a tte n tion o n m ain tain in g ideal body w eight. In a d d i tion, th e re a p p e a rs to be m o re m edia attention focusing o n e atin g diso rd ers. T h e typical p a tie n t w ith bulim ia is a y oung fem ale w ho has a history o f b inging on food and th e n p u rg in g by fo rced v om iting.7"14,17 Fasting, cathartics, diuretics, o r any com bination o f the th re e , a re o th e r m odes o f p u rg in g .11,24 T h e prevalence o f bulim ia is u n c ertain , b u t esti m ates vary w ith betw een 3% a n d 13% o f college stu d e n ts hav in g bulim ia, w ith 89.5% o f those a f fected bein g fem ale. Som e re sea rc h ers consider this estim a te to be conservative. H alm i and o th e rs 25 fo u n d th e prevalence rate in college stu d e n ts to be 13%, w ith 87% o f those affected bein g fem ale. T h e age o f o n set o f the disease generally is th e teens b u t may vary. Russell18 fo u n d th e m ean age o f o n set to be 18.8 years, w ith a ra n g e o f 13 to 35 years. A b rah am and B e u m o n t13 fo u n d th e m ean age o f o n set to be 17 years, w ith a ra n g e o f 12 to 36 years. In g e n eral, th e re is a delay o f a pproxim ately 4 years fro m th e o n se t o f th e first binge u n til th e p atien t seeks tre a tm e n t fo r bulim ia. T h e self-in d u ced vom iting th a t o ften is seen in a p e rso n with bulim ia usually occurs episodi cally. T re a tin g o n e p a tie n t w ith bulim ia, R us sell18 fo u n d th e p a tie n t’s vom iting to be d e p e n d e n t o n th e social settin g in w hich the patien t fo u n d herself. She was fa r less likely to vom it w hen th e re was risk o f b e in g discovered, such as w hen she was in a stran g e h o u se o r am o n g frien d s. W h en visiting h e r b o yfriend, the p a tie n t w ould starve h e rse lf so th a t she w ould not have to vom it. People w ith bulim ia o ften say th a t th ey e n g ag e in self-induced vom iting m ost 762 ■ JA D A , V ol. 113, N ovem ber 1986
o ften in th e ir hom e, alth o u g h d o in g so with frien d s o r in o th e r locations is n o t u n h e a rd o f.13,23 Pyle a n d o th e rs 23 re p o rte d th a t all 34 patients with bulim ia stu d ied re p o rte d at least weekly binge eatin g , 89% re p o rte d daily binges, 78% re p o rte d daily self-induced vom iting, a n d 86% re p o rte d weekly vom iting. L axative a n d d iu re tic use was less fre q u e n t, with 27% o f the g ro u p re p o rtin g use weekly. T hirty-tw o p e rc e n t fasted fo r 24 h o u rs at least once p e r week. T h e self-induced vom iting m ost o ften is initi a te d by th e p e rso n ’s placing his o r h e r fingers distally in th e m o u th a n d p h ary n x , thus initiat ing th e gag reflex. Som e people with bulim ia d evelop calluses on th e ir fingers a n d h an d s as a re su lt o f re p e a te d friction against th eir teeth. Item s such as a to o th b ru sh , com b, o r stick have been su b stitu te d fo r th e fingers. Som e people w ith bulim ia have a special, p re fe rre d in stru m en t th a t they c arry w ith them to in d u ce vom it in g .9 B efore sta rtin g th e binge episode, a perso n with bulim ia m ay ingest a p a rticu la r m a rk e r food. W hen th e binge is c o m p leted a n d the self-induced vom iting begins, the p a tie n t will search fo r th e m a rk e r to m ake certain th a t all th e food co n su m ed was re g u rg itate d . Foods su c h as ra isin s, r e d a p p le skin, le ttu c e , o r licorice seem to be especially p o p u la r as m ark e rs.13
Oral aspects of bulimia It is th e secretive beh av io r p a tte rn s th a t m ake b u lim ia d iffic u lt to d ia g n o s e . P e o p le w ith bulim ia o ften a re re lu c ta n t to ad m it th e ir bingin g -p u rg in g activity, m ak in g diagnosis d u rin g a ro u tin e physical exam ination difficult if not im possible.15'26,27 T h e oral aspects o f th e dis ease, w hich w ould facilitate its diagnosis, could easily be overlooked. E nam el ero sio n , salivary gland e n la rg em e n t with associated xerostom ia, oral m ucosal irrita tion, a n d cheilosis a re distinct oral m anifesta tions th a t m ay be p re se n t in th e patien t with bulim ia. N o n e o f these conditions is p a th o g n o
m onic o f bulim ia, b u t all a re pathologic co n d i tions th a t m erit exp lan atio n . A constellation o f these signs a n d sym ptom s, a lth o u g h individu ally seem ingly u n re la te d , in conjunction with th e p a tie n t’s general physical a n d psychological h isto ry , s h o u ld m ak e th e c lin ician su sp ec t bulim ia. K now ledge o f these objective signs puts p rim a ry care physicians a n d den tists in a g o o d p o sitio n to d ia g n o s e b u lim ia d u r in g ro u tin e office visits (T able 1). E nam el e rosion is probably th e m ost obvious o ral m anifestation o f bulim ia.28"31 O ver tim e, th e c h ro n ic reg u rg itatio n o f gastric contents h aving a low p H will ero d e tooth enam el. Some a u th o rs32,33 have te rm e d the e n am el erosion t h a t r e s u l ts fro m c h r o n ic r e g u r g i t a t i o n , perim olysis. G eneralized en am el erosion a n d décalcification o f the lingual a n d occlusal su r faces o f th e m axillary teeth should a le rt the clinician to a possible diagnosis o f bulim ia (Fig 2, 3). T h e loss o f en am el fro m a re sto red tooth results in re sto ratio n m arg in s above th e enam el, giving th e resto ratio n a characteristic p ro m i n e n c e .28 W h e n th e v o m itin g is c h ro n ic , a sm ooth a n d h o m o g en eo u s loss o f en am el with ex p o sed d e n tin o n th e lingual a n d occlusal su r faces o f the teeth generally is fo u n d .3 In severe cases, th e incisal edges o f th e a n te rio r teeth becom e e ro d e d , p ro d u c in g s h o rte r clinical crow ns. T h is situation can progress to th e p o ste rio r teeth , a n d th e enam el erosion could close th e b ite34 (Fig 4). T h e rm a l tooth hy p e rsen sitiv ity is fairly c o m m o n w ith se v ere en am el erosion as a result o f ex p o sed d e n tin . E nam el usually will not ero d e until re g u rg ita tion has c o n tin u e d fo r at least 2 years.35 O th e r possible diagnoses in a p a tie n t h aving e n am el e rosion a re ra th e r rem ote. People e at ing a highly acidic diet— fo r exam ple, sucking o n lem ons— m ay e x p erien c e en am el e ro sio n .35 People em ployed in jo b s w ith atm ospheric acid m ay e x p erien c e en am el ero sio n .36 E nam el e ro sion was re p o rte d to occu r in people w ho swam in highly c h lo rin ate d w ater. C hlo rin e leads to d ecreased o ral p H th ro u g h th e fo rm atio n o f acid, with sub seq u en t dissolution o f the e n am el.37 T h e fo reg o in g th re e conditions, how-
Table 1 ■ Oral signs and symptoms assisting in the diagnosis of bulimia. O ral c o n d itio n E n am el e ro sio n (perim olysis)
Salivary g lan d e n la rg e m e n t X ero sto m ia O ra l m ucosa irrita tio n
C heilosis
Clinical fe a tu re s E rosion o f enam el, prim arily o n m axillary te e th , o n lingual an d occlusal surfaces; th e rm a l hypersensitivity E n larg em e n t o f p a ro tid an d som etim es su b m an d ib u lar; may o r may n o t be painful D ryness o f m o u th , d e crea sed salivary flow E ry th em a, especially o f p h a ry n x a n d palate; m ay also include gingiva
R ed d e n e d , d ry , crack in g lips, w ith fissures a t angles o f lips
Etiologic factor A cid p H o f re g u rg ita te d gastric contents
Possibly m etabolic
D ecreased salivary o u tp u t; d e p re ssio n , anxiety A cid p H o f re g u rg ita te d gastric con ten ts; tra u m a fro m ra p id food ingestion; tra u m a fro m self-induced vom iting V ita m in deficiency, especially B com plex; acid p H o f g astric c o ntents
CLINICAL
Fig 2 ■ M axillary arch. Severe enam el erosion is evident on the lingual surface of the anterior teeth and the occlusal surface o f the posterior teeth. T h is is characteristic o f bulim ia. T he right side o f th e arch has been rem oved.
Fig 3 ■ M andibular arch. Note the craterlike enam el erosion o f the m olars. T he right side of the arch already has been restored.
ever, will pro d u ce enam el erosion on th e facial surface o f the teeth a n d little erosion o n th e lin gual o r occlusal. E n larg em en t o f the p a ro tid glan d a n d occa sionally th e sub m an d ib u lar g land, e ith e r p a in ful o r asym ptom atic, m ay be noticed in th e p a tie n t w ith bulim ia.38'43 X erostom ia som etim es is associated with th e g la n d u la r e n la rg em e n t a n d results in decreased salivary glan d o u tp u t. A d ditionally, the typical patien t with bulim ia o ften has significant anxiety o r d epression, b oth o f which can co n trib u te to xerostom ia. A lthough case re p o rts o f p eople w ith bulim ia a n d paro tid e n la rg em e n t a re few, Levin a n d o th e rs43 noted ten o f 20 patients with bulim ia h a d perio d s o f p a ro tid e n la rg em e n t. T h e e n la rg e m e n t m ay persist fo r a p erio d a fte r the bulim ia is re solved.42 T h e cause o f th e salivary gland en la rg em e n t is unknow n. O th e r conditions associated with p a ro tid e n la rg em e n t m ay suggest a cause o f bulim ia. T ra n s ie n t p a ro tid e n la rg e m e n t has been re p o rte d in cases o f e x tre m e m aln u tritio n a n d ingestion o f starch, parotitis, S jogren’s syn d ro m e, Mikulicz’s disease, sarcoid sialadenitis, H e e rfo rd t’s syndrom e, a n d tuberculosis.39,40,44 M etabolic sialadenosis has been d e fin e d as a nonspecific alteration o f th e salivary glands re sulting fro m a variety o f generalized m etabolic disorders. Most com m only, the e n la rg em e n t h a s b e e n n o tic e d in p a tie n ts w ith e n d o c rinopathies a n d diabetes m ellitus.38,39,41"44 O ral m ucosal ery th e m a has been o bserved as a consequence o f chronic irritatio n by gastric
REPORTS
usual. Similarly, oral mucosal erythem a is explained readily by the diagnosis o f bulimia. T reatm ent o f the dental sequelae of bulimia should commence as soon as pos sible.46 Once enamel has eroded, it will not regenerate, and dental restorations may be required. In mild cases, intensive top ical fluorides are indicated to remineralize the enamel. In severe cases, crowns or other restorations are indicated. T he soft tissue involvement will im prove as the bulimia resolves and the patient’s diet and nutritional status stabilize. Bulimia is a complex disorder that usu ally is not diagnosed d u rin g a routine physical examination. Rather, people with bulim ia typically re fe r them selves for treatm ent after years o f having the dis Discussion ease. An awareness o f the objective oral Although five specific oral diagnostic con signs and symptoms o f bulimia may help ditions have been reviewed, it is unusual the clinician make a diagnosis at an earlier for any one patient with bulimia to have all stage of the disease. five. Rather, a person with bulimia usually has several o f the signs and symptoms with Summary perhaps only early o r trace indications of others. Several patients had pathological Bulimia is an eating disorder disease that conditions th at w ere at such an early p re se n ts d iffic u lties in its diagnosis, stage— fo r exam ple, p aro tid e n la rg e primarily because of the secretive nature m ent—that had the health care profes o f the person with the disease. T he disease sional not known that the patients had is most common in young females, and bulimia, the pathologic condition would there is an average o f a 4-year delay be tween the onset o f the disease and the pa have gone unnoticed. T he single most easily noticed clinical tient’s self-referral for treatm ent. Objec sign o f bulimia has been enamel erosion tive oral signs and symptoms o f bulimia do (perimolysis), specifically on the lingual exist and their presence can facilitate a and occlusal surfaces of the maxillary den diagnosis o f bulimia during routine exam tition. T here is a wide range o f severity of ination. T he realization that five oral signs erosion, but it is a consistent phenom enon. and symptoms o f bulimia—enamel ero T he clinician who notices enamel erosion, sion, salivary gland enlargem ent, xero especially on the teeth o f a young female, stom ia, o ral m ucosal e ry th e m a , and should consider it to be a prim ary sign in cheilosis—are associated with the disease can eliminate some laboratory tests as well the diagnosis of bulimia. Conversely, a knowledge o f the oral as facilitate an earlier diagnosis of bulimia. manifestations of bulimia may eliminate --------------------- j m A -----------------------the necessity for additional laboratory D r. A bram s is associate p ro fe sso r o f c om m unity evaluation. T he developm ent of any of h e alth , a n d h e ad , division o f com m u n ity den tistry ; Dr. these manifestations in a person known to R u ff is assistant p ro fe sso r o f co m m u n ity h e alth , a n d have bulimia is most likely a part o f the d ire c to r, special p a tie n t clinic, d e p a rtm e n t o f c o m m u natural history and not a second disease. nity health, M arq u ette U niversity School o f D entistry, For example, once a diagnosis o f bulimia 604 N 16th St, M ilw aukee, 53233. A d d re ss requests fo r re p rin ts to D r. A bram s. has been established, the presence of en larged salivary glands would not be un1. A m e ric a n P sychiatric A ssociation. D iagnostic contents. Frequently, p h ary n g eal, palatal, and gingival soreness is fo u n d in a p a tie n t w ith a his to ry o f f r e q u e n t v o m itin g a n d h a v e b e e n noticed in th e patients w ho have bulim ia. T h e vom iting, being self-induced, o ften produces lacerations a n d abrasions in th e m o u th fro m use o f fingers o r from o th e r devices used by th e pa tie n t.45 T h e acidic n a tu re o f the stom ach con tents contributes as a local irrita n t to the oral a n d pharyngeal m ucosa. Cheilosis is an oral condition characterized by dry , re d , a n d cracking lips, especially a t th e an gles, a n d som etim es has been noticed in people with bulim ia. Systemic factors involved in the o n set o f cheilosis m ay include vitam in d efi ciency, as a result o f im p ro p e r d iet a n d sub se q u e n t a lte re d m etabolism . Local irrita tio n also is a factor, as a re su lt o f th e acid p H o f the re g u rg itate d gastric contents.
F ig4 ■ Severe enam el erosion o f incisal edges of anterior teeth, which produces a shorter clinical crown and closure of the bite.
a n d statistical m a n u a l o f m e n ta l d iso rd e rs, e d 3. W ash ing to n , DC, A m e ric a n Psychiatric A ssociation, 1980, p p 69-71. 2. S tangler, R.S., a n d Printz, A.M . D SM -III: psy chiatric diagnosis in a university p o p u la tio n . A m J Psy chiatry 137(8):937-940, 1980. 3. K leier, D .J.; A rag o n , S.B.; a n d A verbach, R.E. D ental m a n a g em e n t o f th e c h ro n ic vom iting pa tie n t. JA D A 108(4) :6 18-621, 1984. 4. H a rriso n , J.L .; G eorge, L.A .; a n d C h ea th a m , J.L . T h e ra p ie s fo r a re d u c tio n o f d e n ta l d e stru ctio n re su lt in g fro m th e m a nifestations o f bulim ia nervosa. T e x
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Dent J 101:12-15, 1984. 5. H arrison, J.L., and others. Dental effects and m anagem ent o f bulimia nervosa. Gen Dent 33:65-68, 1985. 6. Blackman, P., ed. Mishnayoth, O rder Moed, vol 2. New York, Judaica Press, Inc, 1963, p 310. 7. S tu n k ard , A.J. E ating p attern s an d obesity. Psychiatr Q 33:284-292, 1959. 8. Johnson, C., and Berndt, D.J. Preliminary inves tigation o f bulimia and life adjustm ent. Am J Psychia try 140(6):774-777, 1983. 9. G andour, M.J. Bulimia: clinical description, as sessment, etiology, and treatm ent. In t J Eating Disor ders 3(3):3-38, 1984. 10. Halmi, K.A. Anorexia nervosa and bulimia. Psychosomatics 24(2): 111-129, 1983. 11. Fairburn, C.G., and Cooper, P.J. T h e clinical features of bulim ia nervosa. B r J Psychiatry 144:238246, 1984. 12. Bailey, S. Diagnosing bulimia. Am Fam Physi cian 29(5): 161-164, 1984. 13. Abraham , S.F., and Beum ont, P.J. How patients d escrib e b u lim ia o r b in g e ea tin g . Psychol M ed 12:625-635, 1982. 14. Johnson, R.E., and Sinnott, S.K. Bulimia. Am Fam Physician 24(1): 141-143, 1981. 15. H uo n , G.F., and Brow n, L.B. Bulimia: the em ergence o f a syndrom e. A ust NZ J Psychiatry 18:113-126, 1984. 16. Brady, W.F. T h e anorexia nervosa syndrome. O ral S urg 50:509-516, 1980. 17. Fairburn, C.G., and Cooper, P.J. Binge eating, self-induced vomiting and laxative abuse: a com mu nity study. Psychol Med 14:401-410, 1984. 18. Russell, G. Bulimia nervosa: an ominous variant o f anorexia nervosa. Psychol Med 9:429-448, 1979. 19. Casper, R.C., and others. Bulimia, its incidence and clinical im portance in patients with anorexia ner vosa. A rch Gen Psychiatry 37:1030-1035, 1980.
764 ■ JADA, Vol. 113, November 1986
20. Hillard, J.R .; Lobo, M.C.; and Keeling, R.P. Bulimia and diabetes: a potentially life-threatening combination. Psychosomatics 24(3):292-295, 1983. 21. H arris, R.T. Bulimarexia and related serious eating disorders with medical complications. A nn Intern Med 99:800-807, 1983. 22. Matikainen, M. Spontaneous ru p tu re o f the stomach. Am J Surg 138:451-452, 1979. 23. Pyle, R.L.; Mitchell, J.E .; an d Eckert, E.D. Bulimia: a rep o rt o f 34 cases. J Clin Psychiatry 42:6064, 1981. 24. Maloney, M.J., and Klykylo, W.M. An overview o f anorexia nervosa, bulimia, and obesity in children a n d a d o le sc e n ts. J Am A cad C h ild P sy ch ia try 22(2):99-107, 1983. 25. Halmi, K.A.; Falk, J.R.; and Schwartz, E. Binge eating and vomiting: a survey o f a college population. Psychol Med 11:697-706, 1981. 26. Johnson, C.; Lewis, C.; and Hagm an, J . T he syndrome o f bulimia, review and synthesis. Psychiatr Clin N orth Am 7(2):247-273, 1984. 27. Swift, W.J., and Letven, R. Bulimia and the basic fault: a psychoanalytic interpretation o f the binging-vomiting syndrome. J Am Acad Child Psychi atry 23(4):489-497, 1984. 28. Andrews, F.F. Dental erosion due to anorexia nervosa with bulimia. B r Dent J 152:89-90, 1982. 29. Wolcott, R.B.; Yager, J.; and Gordon, G. Dental sequelae to the binge-purge syndrom e (bulimia): re p o rt o f cases. JADA 109(5):723-725, 1984. 30. White, D.K.; Hayes, R.C.; and Benjamin, R.N. Loss o f tooth structure associated with chronic reg u r gitation and vomiting. JADA 97(5):833-835, 1978. 31. Miller, W.D. Experim ents and observations on the wasting o f tooth tissue variously designated as ero sion, abrasion, chemical abrasion, denudation, etc. Dent Cosmos 49(2): 109-124, 1907. 32. House, R.C., and others. Perimolysis: unveiling th e surreptitious vom iter. O ral S urg 51:152-155,
1981. 33. Hellstrom, I. O ral complications in anorexia nervosa. Scand J Dent Res 85:71-86, 1977. 34. Cauwels, J.M . Bulimia—the binge purge com pulsion. G arden City, NY. Doubleday and Co, Inc, 1983, pp 84-86. 35. Stafne, E.C., and Lovestedt, S.A. Dissolution of tooth substance by lem on juice, acid beverages and acids from other sources. JA DA 34(5):586-592, 1947. 36. Bruggen Cate, H.F. Dental erosion in industry. Br J In d Med 25:249-266, 1968. 37. Centers for Disease Control. Erosion o f dental enam el am ong com petitive sw im m ers—V irginia. MMWR 32(28):361-362, 1983. 38. Ahola, S.J. Unexplained parotid enlargem ent: a clue to occult bulimia. Conn Med 46(4): 185-186, 1982. 39. Katsilambros, L. Asymptomatic enlargem ent of the parotid glands. JA M A 178:513-514, 1961. 40. Silverm an, M., an d Perkins, R.L. Bilateral parotid enlargem ent and starch ingestion. Ann In tern Med 64:842-846, 1966. 41. Lavender, S. Vomiting and parotid enlarge m ent. Lancet 1:426, 1969. 42. W alsh, B .T .; C ro ft, C .B .; an d K atz, J.L . Anorexia nervosa and salivary gland enlargem ent. Int J Psychiatry Med 11(3):255-261, 1981. 43. Levin, P.A., and others. Benign parotid en largem ent in bulimia. A nn In tern Med 93:827-829, 1980. 44. Eversole, L.R. Clinical outline o f oral pathology. Philadelphia, Lea 8c Febiger, 1984, pp 185-190. 45. Schaff, J.E . Anorexia nervosa and bulimia: dis orders with oral implications. Alumni Bull Sch Dent Indiana Univ 93(spring): 14-16, 93, 1984. 46. H urst, P.S.; Lacey, J .H.; and Crisp, A.H. T eeth vomiting and diet: a study o f the dental characteristics o f seventeen an o rex ia p atien ts. P ostgrad Med J 53:298-305, 1977.
facial region, especially in older adults. O ral pain, paresthesia, and swelling may be the first signs o f the disease. Summary
A rep o rt o f a case o f metastatic renal cell carcinoma to the mandible in a previously asymptomatic person is presented. Metas tatic disease always m ust be considered in any lesion o f the maxillofacial region, es pecially in older adults. Oral pain, pares thesia, and swelling may be the first signs o f disease.
---------------------J '/O A ----------------------
In fo rm a tio n a b o u t th e m a n u fa c tu re rs o f th e p ro d ucts m e n tio n e d in this article m ay b e available fro m the a u th o rs. N e ith e r th e a u th o rs n o r th e A m erican D ental A ssociation has an y co m m ercial in te re sts in th e p ro d ucts m e n tio n e d . D r. Pick is a s s is ta n t p r o f e s s o r , d e p a r tm e n t o f su rg ery , Case W estern R eserve U niversity School o f M edicine, a n d a tte n d in g o ral a n d m axillofacial s u r g e o n , C le v e la n d M e tr o p o lita n G e n e r a l H o sp ita l, C leveland. D r. W a g n e r is c h ie f re sid en t, d e p a rtm e n t o f o ra l a n d m axillofacial su rg e ry , C leveland M et ro p o lita n G e n eral H o sp ital, C leveland. D r. In d re sa n o is associate p ro fesso r, d e p a r tm e n t o f su rg e ry , Case W estern R eserve U niversity School o f M edicine, an d d ir e c to r , d e p a r t m e n t o f o r a l a n d m a x illo fa c ia l su rg ery , C leveland M etro p o lita n G en eral H ospital, 3395 S c ra n to n R d, C leveland, 4 4 109. A d d re ss re qu ests fo r re p rin ts to D r. In d re sa n o .
REPORTS
1. C lau sen , R., a n d P oulsen, H . M etastatic c a r cinom a to th e jaw s. A cta P ath o l M icro Scand 57:361374, 1963. 2. S h a fe r, W .G.; H in e , M .K.; a n d Levy, B.M . A tex tb o o k o f o ral p a thology, ed 4. P hilad elp h ia, W. B. S a u n d e rs Co, 1983. 3. Sachs, R .L . M etastatic c a rc in o m a to th e ja w bones. T h e sis, N ew Y ork U niversity, 1982. 4. M cD aniel, R .I.; L u n a , M .A.; a n d S tinson, P.G. M etastatic tu m o rs in th e jaw s. O ra l S u rg 31:380-386, 1971. 5. N ish im u ra , Y., a n d o th e rs. M etastatic tu m o rs o f th e m o u th a n d jaws. T O ra l M axillofac S u rg 10:253258, 1982. 6. van d e r K wast, W .A ., a n d van d e r W aal, I. Jaw m etastases. O ra l S u rg 37(6):850-857, 1974. 7. Boles, R., a n d C erny, J . H e a d a n d n eck m etas tases fro m ren al cell carcinom as. Mich M ed 70:616, 1971.
Oral signs and symptoms in the diagnosis of bulimia R ichard A . A bram s, DDS, MPH, MEd J e sle y C. R u ff, DDS
The oral characteristics o f patients with bulim ia are reviewed. Aw areness by the clinician o f these characteristics can fa c ili tate a diagnosis o f bulim ia during routine exam ination.
Description and diagnosis
O n e o f th e m o st p e r p le x in g p ro b le m s a s sociated w ith bulim ia has b e en to establish an a c c u ra te d e fin itio n o f th e en tity . B u lim ia’s m ajor fe atu res a re episodic binge eating ac co m p an ied by a p erce p tio n th a t this p a tte rn o f e atin g is a b n o rm al, fe a r o f b ein g u nable to stop ulimia is an eating disorder that e atin g voluntarily, a n d a d e p ressed m ood and gradually is being discussed in both s e lf- d e p re c a tin g th o u g h ts a f te r th e e a tin g bin g es.716 T h e binges usually a re follow ed by lay and professional circles. T he self-induced vom iting. It is im p o rta n t to d istin disease has a deceptive clinical picture, guish bulim ia fro m a n o rex ia nervosa a n d to and it has been difficult to develop diag ru le o u t o rg a n ic d iso rd e r. A norexia nervosa is nostic criteria to pinpoint w hether a per c h aracterized by a w eight loss o f at least 25% o f son has bulimia. T he American Psychiatric original body w eight. In ra re circum stances, an A s s o c ia tio n 1 a n d i n d e p e n d e n t r e episode o f a n o rex ia nervosa occurs in people
B
searchers2 suggested diagnostic criteria for bulimia and stated that it was an eating d is o r d e r c h a r a c te r iz e d by re p e a te d episodes o f binge eating associated with self-induced vomiting (Fig 1). T he disease has distinct oral consequences in addition to physical an d psychological con se quences.3"5 T he word bulimia literally means ox hunger, indicating voraciousness. O ne of the first recorded instances o f bulimia as a distinct entity is found in the Talm ud, a collection o f Jewish law several thousand years old. T he M ishnah,6 or written por tion o f the T alm ud, speaks o f a person’s being perm itted to eat on Yom K ippur, a traditional holy fasting day, if the person had bulimia.
with bulim ia, in w hich case b oth diagnoses are given.1 In g e n era l, th e e atin g binges a re p lan n e d , a n d usually th e ing ested food is o f an easily swal lo w e d c o n s is te n c y , h ig h in c a lo r ie s , a n d sw eet.9,1117“19 O fte n th e fo o d is e aten rapidly, w ith little c h e w in g , a n d s e c re tiv e ly .9 T h e a m o u n t o f fo o d in g este d d u rin g th e e atin g binge m ay vary, b u t re p o rts o f 3,000 to 6,000 calories seem to b e th e average, with som e re p o r ts o f u p to 2 0 ,0 0 0 c a lo rie s in 1 to 2 h o u rs .18,20,21 A p e rso n w ith bulim ia feels a loss o f co n tro l d u rin g binge e atin g a n d states th a t it is im possible to stop eating. T h e binge con cludes as a re su lt o f abdom inal pain, sleep, so cial in te rru p tio n , o r self-induced vom iting. Al th o u g h ex tre m e ly ra re , sp o n ta n eo u s ru p tu r e o f
■ R ecurrent episodes o f binge eating (rapid consum ption o f a large am ount of food in a discrete period, usually less than 2 hours). ■ At least th ree o f the following: C onsum ption o f high-caloric, easily ingested food d u rin g a binge. Inconspicuous eating d u rin g a binge. Term ination o f such eating episodes by abdom inal pain, sleep, social in terruption, or self-induced vomiting. R epeated attem pts to lose w eight by severely restrictive diets, self-induced vom iting, o r use of cathartics or diuretics. Frequent w eight fluctuations greater than 10 lb due to alternating binges and fasts. ■ Awareness th at the eating p attern is abnorm al and fear o f not being able to stop eating voluntarily. ■ D epressed m ood and self-deprecating thoughts follow ing eating binges. ■ T he bulim ic episodes are not due to anorexia nervosa or any know n physical disorder. Fig 1 ■ D iagnostic criteria fo r bulim ia (adapted from Diagnostic and Statistical M anual o f M ental Dis orders').
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REPORTS
the stom ach has been re la te d to bulim ia.22 T h e self-induced vom iting relieves the abdom inal discom fort a n d Ih e self-d ep recatin g feelings. As a ru le, th e binge itself is pleasurable, b u t the sequelae a re not. P reo ccu p atio n a n d concern w ith th e ir w eight is noticed in p eo p le with bulim ia. T raditionally, a p a tie n t w ith bulim ia has a history o f dieting; vom iting; use o f laxatives, cathartics, o r d iu re tics; o r a com b in atio n o f th e fo reg o in g charac teristics. T h e A m e ric an Psychiatric A ssocia tio n ’s d e fin itio n d oes n o t m an d a te th at a p erso n follow th e b inge e atin g by self-induced vom it ing o r laxatives to have bulim ia, b u t m ost p e r sons w ith bulim ia d o so.9' 11-13,14-23 R ussell18 listed th e follow ing th re e criteria fo r a diagnosis o f “bulim ia nervosa”: p atients e x p e rience p o w e rfu l a n d intractable urges to o ver eat; seek to avoid fa tten in g effects o f food by self-induced vom iting; a n d have a m orbid fe a r o f b ecom ing fat. O nly recently was bulim ia d e fin e d as a dis tinct disease. C a n d o u r9 p o in te d o u t th a t th e re a re su b g ro u p s o f p atien ts h av in g a n o rex ia n e r vosa w ho vom ited a n d binged. A diagnosis o f bulim ia does n o t d e p e n d o n th e p a tie n t’s having lost w eight, a n d o ften th e p ersons with bulim ia a re o f n o rm al w eight o r 5 to 15 lb overw eight.12
Epidemiologic characteristics E atin g d iso rd e rs such as bulim ia m ay be m ore p re v alen t as a re su lt o f increased social a tte n tion o n m ain tain in g ideal body w eight. In a d d i tion, th e re a p p e a rs to be m o re m edia attention focusing o n e atin g diso rd ers. T h e typical p a tie n t w ith bulim ia is a y oung fem ale w ho has a history o f b inging on food and th e n p u rg in g by fo rced v om iting.7"14,17 Fasting, cathartics, diuretics, o r any com bination o f the th re e , a re o th e r m odes o f p u rg in g .11,24 T h e prevalence o f bulim ia is u n c ertain , b u t esti m ates vary w ith betw een 3% a n d 13% o f college stu d e n ts hav in g bulim ia, w ith 89.5% o f those a f fected bein g fem ale. Som e re sea rc h ers consider this estim a te to be conservative. H alm i and o th e rs 25 fo u n d th e prevalence rate in college stu d e n ts to be 13%, w ith 87% o f those affected bein g fem ale. T h e age o f o n set o f the disease generally is th e teens b u t may vary. Russell18 fo u n d th e m ean age o f o n set to be 18.8 years, w ith a ra n g e o f 13 to 35 years. A b rah am and B e u m o n t13 fo u n d th e m ean age o f o n set to be 17 years, w ith a ra n g e o f 12 to 36 years. In g e n eral, th e re is a delay o f a pproxim ately 4 years fro m th e o n se t o f th e first binge u n til th e p atien t seeks tre a tm e n t fo r bulim ia. T h e self-in d u ced vom iting th a t o ften is seen in a p e rso n with bulim ia usually occurs episodi cally. T re a tin g o n e p a tie n t w ith bulim ia, R us sell18 fo u n d th e p a tie n t’s vom iting to be d e p e n d e n t o n th e social settin g in w hich the patien t fo u n d herself. She was fa r less likely to vom it w hen th e re was risk o f b e in g discovered, such as w hen she was in a stran g e h o u se o r am o n g frien d s. W h en visiting h e r b o yfriend, the p a tie n t w ould starve h e rse lf so th a t she w ould not have to vom it. People w ith bulim ia o ften say th a t th ey e n g ag e in self-induced vom iting m ost 762 ■ JA D A , V ol. 113, N ovem ber 1986
o ften in th e ir hom e, alth o u g h d o in g so with frien d s o r in o th e r locations is n o t u n h e a rd o f.13,23 Pyle a n d o th e rs 23 re p o rte d th a t all 34 patients with bulim ia stu d ied re p o rte d at least weekly binge eatin g , 89% re p o rte d daily binges, 78% re p o rte d daily self-induced vom iting, a n d 86% re p o rte d weekly vom iting. L axative a n d d iu re tic use was less fre q u e n t, with 27% o f the g ro u p re p o rtin g use weekly. T hirty-tw o p e rc e n t fasted fo r 24 h o u rs at least once p e r week. T h e self-induced vom iting m ost o ften is initi a te d by th e p e rso n ’s placing his o r h e r fingers distally in th e m o u th a n d p h ary n x , thus initiat ing th e gag reflex. Som e people with bulim ia d evelop calluses on th e ir fingers a n d h an d s as a re su lt o f re p e a te d friction against th eir teeth. Item s such as a to o th b ru sh , com b, o r stick have been su b stitu te d fo r th e fingers. Som e people w ith bulim ia have a special, p re fe rre d in stru m en t th a t they c arry w ith them to in d u ce vom it in g .9 B efore sta rtin g th e binge episode, a perso n with bulim ia m ay ingest a p a rticu la r m a rk e r food. W hen th e binge is c o m p leted a n d the self-induced vom iting begins, the p a tie n t will search fo r th e m a rk e r to m ake certain th a t all th e food co n su m ed was re g u rg itate d . Foods su c h as ra isin s, r e d a p p le skin, le ttu c e , o r licorice seem to be especially p o p u la r as m ark e rs.13
Oral aspects of bulimia It is th e secretive beh av io r p a tte rn s th a t m ake b u lim ia d iffic u lt to d ia g n o s e . P e o p le w ith bulim ia o ften a re re lu c ta n t to ad m it th e ir bingin g -p u rg in g activity, m ak in g diagnosis d u rin g a ro u tin e physical exam ination difficult if not im possible.15'26,27 T h e oral aspects o f th e dis ease, w hich w ould facilitate its diagnosis, could easily be overlooked. E nam el ero sio n , salivary gland e n la rg em e n t with associated xerostom ia, oral m ucosal irrita tion, a n d cheilosis a re distinct oral m anifesta tions th a t m ay be p re se n t in th e patien t with bulim ia. N o n e o f these conditions is p a th o g n o
m onic o f bulim ia, b u t all a re pathologic co n d i tions th a t m erit exp lan atio n . A constellation o f these signs a n d sym ptom s, a lth o u g h individu ally seem ingly u n re la te d , in conjunction with th e p a tie n t’s general physical a n d psychological h isto ry , s h o u ld m ak e th e c lin ician su sp ec t bulim ia. K now ledge o f these objective signs puts p rim a ry care physicians a n d den tists in a g o o d p o sitio n to d ia g n o s e b u lim ia d u r in g ro u tin e office visits (T able 1). E nam el e rosion is probably th e m ost obvious o ral m anifestation o f bulim ia.28"31 O ver tim e, th e c h ro n ic reg u rg itatio n o f gastric contents h aving a low p H will ero d e tooth enam el. Some a u th o rs32,33 have te rm e d the e n am el erosion t h a t r e s u l ts fro m c h r o n ic r e g u r g i t a t i o n , perim olysis. G eneralized en am el erosion a n d décalcification o f the lingual a n d occlusal su r faces o f th e m axillary teeth should a le rt the clinician to a possible diagnosis o f bulim ia (Fig 2, 3). T h e loss o f en am el fro m a re sto red tooth results in re sto ratio n m arg in s above th e enam el, giving th e resto ratio n a characteristic p ro m i n e n c e .28 W h e n th e v o m itin g is c h ro n ic , a sm ooth a n d h o m o g en eo u s loss o f en am el with ex p o sed d e n tin o n th e lingual a n d occlusal su r faces o f the teeth generally is fo u n d .3 In severe cases, th e incisal edges o f th e a n te rio r teeth becom e e ro d e d , p ro d u c in g s h o rte r clinical crow ns. T h is situation can progress to th e p o ste rio r teeth , a n d th e enam el erosion could close th e b ite34 (Fig 4). T h e rm a l tooth hy p e rsen sitiv ity is fairly c o m m o n w ith se v ere en am el erosion as a result o f ex p o sed d e n tin . E nam el usually will not ero d e until re g u rg ita tion has c o n tin u e d fo r at least 2 years.35 O th e r possible diagnoses in a p a tie n t h aving e n am el e rosion a re ra th e r rem ote. People e at ing a highly acidic diet— fo r exam ple, sucking o n lem ons— m ay e x p erien c e en am el e ro sio n .35 People em ployed in jo b s w ith atm ospheric acid m ay e x p erien c e en am el ero sio n .36 E nam el e ro sion was re p o rte d to occu r in people w ho swam in highly c h lo rin ate d w ater. C hlo rin e leads to d ecreased o ral p H th ro u g h th e fo rm atio n o f acid, with sub seq u en t dissolution o f the e n am el.37 T h e fo reg o in g th re e conditions, how-
Table 1 ■ Oral signs and symptoms assisting in the diagnosis of bulimia. O ral c o n d itio n E n am el e ro sio n (perim olysis)
Salivary g lan d e n la rg e m e n t X ero sto m ia O ra l m ucosa irrita tio n
C heilosis
Clinical fe a tu re s E rosion o f enam el, prim arily o n m axillary te e th , o n lingual an d occlusal surfaces; th e rm a l hypersensitivity E n larg em e n t o f p a ro tid an d som etim es su b m an d ib u lar; may o r may n o t be painful D ryness o f m o u th , d e crea sed salivary flow E ry th em a, especially o f p h a ry n x a n d palate; m ay also include gingiva
R ed d e n e d , d ry , crack in g lips, w ith fissures a t angles o f lips
Etiologic factor A cid p H o f re g u rg ita te d gastric contents
Possibly m etabolic
D ecreased salivary o u tp u t; d e p re ssio n , anxiety A cid p H o f re g u rg ita te d gastric con ten ts; tra u m a fro m ra p id food ingestion; tra u m a fro m self-induced vom iting V ita m in deficiency, especially B com plex; acid p H o f g astric c o ntents
CLINICAL
Fig 2 ■ M axillary arch. Severe enam el erosion is evident on the lingual surface of the anterior teeth and the occlusal surface o f the posterior teeth. T h is is characteristic o f bulim ia. T he right side o f th e arch has been rem oved.
Fig 3 ■ M andibular arch. Note the craterlike enam el erosion o f the m olars. T he right side of the arch already has been restored.
ever, will pro d u ce enam el erosion on th e facial surface o f the teeth a n d little erosion o n th e lin gual o r occlusal. E n larg em en t o f the p a ro tid glan d a n d occa sionally th e sub m an d ib u lar g land, e ith e r p a in ful o r asym ptom atic, m ay be noticed in th e p a tie n t w ith bulim ia.38'43 X erostom ia som etim es is associated with th e g la n d u la r e n la rg em e n t a n d results in decreased salivary glan d o u tp u t. A d ditionally, the typical patien t with bulim ia o ften has significant anxiety o r d epression, b oth o f which can co n trib u te to xerostom ia. A lthough case re p o rts o f p eople w ith bulim ia a n d paro tid e n la rg em e n t a re few, Levin a n d o th e rs43 noted ten o f 20 patients with bulim ia h a d perio d s o f p a ro tid e n la rg em e n t. T h e e n la rg e m e n t m ay persist fo r a p erio d a fte r the bulim ia is re solved.42 T h e cause o f th e salivary gland en la rg em e n t is unknow n. O th e r conditions associated with p a ro tid e n la rg em e n t m ay suggest a cause o f bulim ia. T ra n s ie n t p a ro tid e n la rg e m e n t has been re p o rte d in cases o f e x tre m e m aln u tritio n a n d ingestion o f starch, parotitis, S jogren’s syn d ro m e, Mikulicz’s disease, sarcoid sialadenitis, H e e rfo rd t’s syndrom e, a n d tuberculosis.39,40,44 M etabolic sialadenosis has been d e fin e d as a nonspecific alteration o f th e salivary glands re sulting fro m a variety o f generalized m etabolic disorders. Most com m only, the e n la rg em e n t h a s b e e n n o tic e d in p a tie n ts w ith e n d o c rinopathies a n d diabetes m ellitus.38,39,41"44 O ral m ucosal ery th e m a has been o bserved as a consequence o f chronic irritatio n by gastric
REPORTS
usual. Similarly, oral mucosal erythem a is explained readily by the diagnosis o f bulimia. T reatm ent o f the dental sequelae of bulimia should commence as soon as pos sible.46 Once enamel has eroded, it will not regenerate, and dental restorations may be required. In mild cases, intensive top ical fluorides are indicated to remineralize the enamel. In severe cases, crowns or other restorations are indicated. T he soft tissue involvement will im prove as the bulimia resolves and the patient’s diet and nutritional status stabilize. Bulimia is a complex disorder that usu ally is not diagnosed d u rin g a routine physical examination. Rather, people with bulim ia typically re fe r them selves for treatm ent after years o f having the dis Discussion ease. An awareness o f the objective oral Although five specific oral diagnostic con signs and symptoms o f bulimia may help ditions have been reviewed, it is unusual the clinician make a diagnosis at an earlier for any one patient with bulimia to have all stage of the disease. five. Rather, a person with bulimia usually has several o f the signs and symptoms with Summary perhaps only early o r trace indications of others. Several patients had pathological Bulimia is an eating disorder disease that conditions th at w ere at such an early p re se n ts d iffic u lties in its diagnosis, stage— fo r exam ple, p aro tid e n la rg e primarily because of the secretive nature m ent—that had the health care profes o f the person with the disease. T he disease sional not known that the patients had is most common in young females, and bulimia, the pathologic condition would there is an average o f a 4-year delay be tween the onset o f the disease and the pa have gone unnoticed. T he single most easily noticed clinical tient’s self-referral for treatm ent. Objec sign o f bulimia has been enamel erosion tive oral signs and symptoms o f bulimia do (perimolysis), specifically on the lingual exist and their presence can facilitate a and occlusal surfaces of the maxillary den diagnosis o f bulimia during routine exam tition. T here is a wide range o f severity of ination. T he realization that five oral signs erosion, but it is a consistent phenom enon. and symptoms o f bulimia—enamel ero T he clinician who notices enamel erosion, sion, salivary gland enlargem ent, xero especially on the teeth o f a young female, stom ia, o ral m ucosal e ry th e m a , and should consider it to be a prim ary sign in cheilosis—are associated with the disease can eliminate some laboratory tests as well the diagnosis of bulimia. Conversely, a knowledge o f the oral as facilitate an earlier diagnosis of bulimia. manifestations of bulimia may eliminate --------------------- j m A -----------------------the necessity for additional laboratory D r. A bram s is associate p ro fe sso r o f c om m unity evaluation. T he developm ent of any of h e alth , a n d h e ad , division o f com m u n ity den tistry ; Dr. these manifestations in a person known to R u ff is assistant p ro fe sso r o f co m m u n ity h e alth , a n d have bulimia is most likely a part o f the d ire c to r, special p a tie n t clinic, d e p a rtm e n t o f c o m m u natural history and not a second disease. nity health, M arq u ette U niversity School o f D entistry, For example, once a diagnosis o f bulimia 604 N 16th St, M ilw aukee, 53233. A d d re ss requests fo r re p rin ts to D r. A bram s. has been established, the presence of en larged salivary glands would not be un1. A m e ric a n P sychiatric A ssociation. D iagnostic contents. Frequently, p h ary n g eal, palatal, and gingival soreness is fo u n d in a p a tie n t w ith a his to ry o f f r e q u e n t v o m itin g a n d h a v e b e e n noticed in th e patients w ho have bulim ia. T h e vom iting, being self-induced, o ften produces lacerations a n d abrasions in th e m o u th fro m use o f fingers o r from o th e r devices used by th e pa tie n t.45 T h e acidic n a tu re o f the stom ach con tents contributes as a local irrita n t to the oral a n d pharyngeal m ucosa. Cheilosis is an oral condition characterized by dry , re d , a n d cracking lips, especially a t th e an gles, a n d som etim es has been noticed in people with bulim ia. Systemic factors involved in the o n set o f cheilosis m ay include vitam in d efi ciency, as a result o f im p ro p e r d iet a n d sub se q u e n t a lte re d m etabolism . Local irrita tio n also is a factor, as a re su lt o f th e acid p H o f the re g u rg itate d gastric contents.
F ig4 ■ Severe enam el erosion o f incisal edges of anterior teeth, which produces a shorter clinical crown and closure of the bite.
a n d statistical m a n u a l o f m e n ta l d iso rd e rs, e d 3. W ash ing to n , DC, A m e ric a n Psychiatric A ssociation, 1980, p p 69-71. 2. S tangler, R.S., a n d Printz, A.M . D SM -III: psy chiatric diagnosis in a university p o p u la tio n . A m J Psy chiatry 137(8):937-940, 1980. 3. K leier, D .J.; A rag o n , S.B.; a n d A verbach, R.E. D ental m a n a g em e n t o f th e c h ro n ic vom iting pa tie n t. JA D A 108(4) :6 18-621, 1984. 4. H a rriso n , J.L .; G eorge, L.A .; a n d C h ea th a m , J.L . T h e ra p ie s fo r a re d u c tio n o f d e n ta l d e stru ctio n re su lt in g fro m th e m a nifestations o f bulim ia nervosa. T e x
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Dent J 101:12-15, 1984. 5. H arrison, J.L., and others. Dental effects and m anagem ent o f bulimia nervosa. Gen Dent 33:65-68, 1985. 6. Blackman, P., ed. Mishnayoth, O rder Moed, vol 2. New York, Judaica Press, Inc, 1963, p 310. 7. S tu n k ard , A.J. E ating p attern s an d obesity. Psychiatr Q 33:284-292, 1959. 8. Johnson, C., and Berndt, D.J. Preliminary inves tigation o f bulimia and life adjustm ent. Am J Psychia try 140(6):774-777, 1983. 9. G andour, M.J. Bulimia: clinical description, as sessment, etiology, and treatm ent. In t J Eating Disor ders 3(3):3-38, 1984. 10. Halmi, K.A. Anorexia nervosa and bulimia. Psychosomatics 24(2): 111-129, 1983. 11. Fairburn, C.G., and Cooper, P.J. T h e clinical features of bulim ia nervosa. B r J Psychiatry 144:238246, 1984. 12. Bailey, S. Diagnosing bulimia. Am Fam Physi cian 29(5): 161-164, 1984. 13. Abraham , S.F., and Beum ont, P.J. How patients d escrib e b u lim ia o r b in g e ea tin g . Psychol M ed 12:625-635, 1982. 14. Johnson, R.E., and Sinnott, S.K. Bulimia. Am Fam Physician 24(1): 141-143, 1981. 15. H uo n , G.F., and Brow n, L.B. Bulimia: the em ergence o f a syndrom e. A ust NZ J Psychiatry 18:113-126, 1984. 16. Brady, W.F. T h e anorexia nervosa syndrome. O ral S urg 50:509-516, 1980. 17. Fairburn, C.G., and Cooper, P.J. Binge eating, self-induced vomiting and laxative abuse: a com mu nity study. Psychol Med 14:401-410, 1984. 18. Russell, G. Bulimia nervosa: an ominous variant o f anorexia nervosa. Psychol Med 9:429-448, 1979. 19. Casper, R.C., and others. Bulimia, its incidence and clinical im portance in patients with anorexia ner vosa. A rch Gen Psychiatry 37:1030-1035, 1980.
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20. Hillard, J.R .; Lobo, M.C.; and Keeling, R.P. Bulimia and diabetes: a potentially life-threatening combination. Psychosomatics 24(3):292-295, 1983. 21. H arris, R.T. Bulimarexia and related serious eating disorders with medical complications. A nn Intern Med 99:800-807, 1983. 22. Matikainen, M. Spontaneous ru p tu re o f the stomach. Am J Surg 138:451-452, 1979. 23. Pyle, R.L.; Mitchell, J.E .; an d Eckert, E.D. Bulimia: a rep o rt o f 34 cases. J Clin Psychiatry 42:6064, 1981. 24. Maloney, M.J., and Klykylo, W.M. An overview o f anorexia nervosa, bulimia, and obesity in children a n d a d o le sc e n ts. J Am A cad C h ild P sy ch ia try 22(2):99-107, 1983. 25. Halmi, K.A.; Falk, J.R.; and Schwartz, E. Binge eating and vomiting: a survey o f a college population. Psychol Med 11:697-706, 1981. 26. Johnson, C.; Lewis, C.; and Hagm an, J . T he syndrome o f bulimia, review and synthesis. Psychiatr Clin N orth Am 7(2):247-273, 1984. 27. Swift, W.J., and Letven, R. Bulimia and the basic fault: a psychoanalytic interpretation o f the binging-vomiting syndrome. J Am Acad Child Psychi atry 23(4):489-497, 1984. 28. Andrews, F.F. Dental erosion due to anorexia nervosa with bulimia. B r Dent J 152:89-90, 1982. 29. Wolcott, R.B.; Yager, J.; and Gordon, G. Dental sequelae to the binge-purge syndrom e (bulimia): re p o rt o f cases. JADA 109(5):723-725, 1984. 30. White, D.K.; Hayes, R.C.; and Benjamin, R.N. Loss o f tooth structure associated with chronic reg u r gitation and vomiting. JADA 97(5):833-835, 1978. 31. Miller, W.D. Experim ents and observations on the wasting o f tooth tissue variously designated as ero sion, abrasion, chemical abrasion, denudation, etc. Dent Cosmos 49(2): 109-124, 1907. 32. House, R.C., and others. Perimolysis: unveiling th e surreptitious vom iter. O ral S urg 51:152-155,
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