BULIMIA NERVOSA AND BINGE EATING DISORDER

OOLKIT GUIDE 7
Detection and management of dental
problems by dentists
June 2019

◼ Bulimia nervosa is characterized by episodes of binge eating (consumption of a large amount of food in
a short period of time, accompanied by a feeling of being out of control) followed by inappropriate
compensatory behaviours, such as: self-induced vomiting, misuse of laxatives, diuretics or other
medicines; fasting; excessive exercise. In addition, self-esteem is unduly influenced by physical
appearance in these individuals. Bulimia sufferers usually have a normal body mass index (BMI) due to
their compensatory behaviours.

◼ Binge eating disorder is characterised by recurrent episodes of binge eating, but without the
inappropriate compensatory behaviour seen in bulimia nervosa. For this reason, binge eating disorder
generally leads to high BMI (overweight or obesity). Binge eating causes significant distress.

DETECTION OF DENTAL PROBLEMS

Consider an eating disorder, particularly in adolescents and young adults, in the presence of:
◼ early erosive wear on the lingual surfaces of the maxillary incisor and canine sector (related to repeated
vomiting);

◼ asymmetric damage to the mandibular molars (possible frequent nocturnal reflux in the event of regular
vomiting: lateral sleeping position);

◼ the presence of multiple caries (active caries disease), which often reflects a poorly balanced diet with
high sugar intake and multiplication of sources (fizzy drinks, snacking) and disorganised eating rhythms;

◼ thermal sensitivity (to cold in particular) or to acids (early periodontal disease).

How to approach the possibility of an eating disorder with the patient

◼ Be in a one-to-one situation with the patient (schedule a time without the presence of accompanying
family or any healthcare personnel).

◼ Ask the patient about the types of foods eaten, the frequency and how they are eaten.

◼ Adopt a kind, non-judgmental approach to the patient, without making them feel guilty.

◼ Use the damage observed as a basis to talk about eating habits.

◼ Provide information about the pathophysiological mechanisms involved and possible dental care
strategies. E.g.: acid reflux for which the cause is to be determined (Gastroesophageal reflux disease
[GERD], vomiting, rumination syndrome, etc.).
DIAGNOSIS OF DENTAL PROBLEMS IN PATIENTS WITH EATING DISORDERS
◼ Faced with a patient with eating disorders, it is recommended to immediately look for the existence of
dental damage and to record this in the patient’s records (BEWE score1).

◼ The diagnosis should be based on an in-depth clinical assessment before any additional tests.

◼ It is recommended to identify:
 the patient’s expectations (aesthetic, pain management, reduction of functional impairment);
 their eating habits (excessive sugary foods, etc.) and any concurrent addictions (smoking, alcohol,
cannabis, opiates, other drugs);
 their medication use (investigation for presence of medication-related reduced saliva production).

EXAMPLES OF IMAGES OF DENTAL PROBLEMS OBSERVED IN THE EVENT OF

EATING DISORDERS

Figure 1. Erosion of the lingual surfaces of the Figure 2. Erosive wear of the vestibular surfaces of
maxillary incisor and canine sector the maxillary incisors caused by acidic drinks
characteristic of repeated vomiting. Initial stage

Figure 3. Erosion of the lingual surfaces of the

Figure 4. Erosive wear of the vestibular surfaces of
maxillary incisor and canine sector characteristic
the maxillary incisors associated with exposure to
of repeated vomiting. Advanced stage
exogenous colouring agents
 Figure 5. Receding gums in a female patient Figure 6. Erosion on the occlusal surface of a
with anorexia and bulimia mandibular molar associated with acid reflux
phenomena

Figure 8. Situation characteristic of nocturnal

Figure 7. Erosive wear of the cusps caused by gastroesophageal reflux with dissymmetry of
repeated vomiting
erosion patterns related to a lateral sleep position.
Bulimic patient

TREATMENT

◼ Conduct classification by therapeutic group to better identify and more effectively manage the clinical
care of these patients.

◼ This classification makes it possible to take into account the associated and frequent complications of
functional problems, loss of vertical dimension of the lower part of the face and the need to take into
account the periodontal work required for a long-term result.

Table 1. Classification by therapeutic group of extensive loss of substance and treatment regimen
strategies.

Category Loss of substance Treatment options

Superficial,
Advice and prophylactic measures
Group 1 enamel (crown),
Restorations contraindicated
dentine (root)

Moderate and isolated, Direct adhesive restorations

Group 2
enamel and dentine Periodontal root coverage
 Category Loss of substance Treatment options
Without functional problems

Pronounced, Direct and/or indirect individual adhesive

Group 3 affecting a group of teeth, restorations

without functional problems Periodontal work often required

Restoration of a functional and balanced

Marked and multiple
occlusal pattern
Deterioration of bite relationships
Group 4 Direct and indirect adhesive restorations; fixed
Without temporomandibular joint dysfunction prosthesis
4a and 4b
Without (4a) or with (4b) loss of vertical 4a: without raising the VDO
dimension of occlusion (VDO)
4b: with raising the VDO

Overall oral rehabilitation in two phases: Phase

Severe and widespread
1: reconstruction with adhesive restoration of
Loss of bite relationships both arches to validate function and aesthetics.
Group 5
Functional problems: Temporomandibular Phase 2: implant and/or tooth-supported
5a and 5b joint dysfunction prosthetic reconstruction

Without (5a) or with (5b) loss of vertical 5a: without raising the VDO
dimension of occlusion (VDO)
5b: with raising the VDO

Lasfargues JJ, Colon P. Odontologie conservatrice restauratrice. Volume 1. Une approche médicale globale. Paris:
CdP; 2009.
Colon P, Lussi A. Minimal intervention dentistry: part 5. Ultra-conservative approach to the treatment of erosive and
abrasive lesions. Br Dent J 2014;216(8):463-8.

DENTAL CARE PLAN

◼ It is recommended to implement non-invasive management of the initial lesions straight away, even in
the absence of control of etiological factors (e.g.: recommend a specific toothpaste, apply an adhesive
resin, etc.).

◼ A check-list may help dentists ensure that all parameters have been properly assessed before deciding
on the more “technical” aspects of the treatment plan.

Dental treatment plan check-list

Carefully examine all the teeth in both dental arches using the BEWE scoring system, for example, and
recording the location and extent by sector. Extensive erosion lesions are never isolated. Significant acid
1
attack cannot be limited to a single tooth. Therefore, a restorative treatment plan should only be decided
upon following an analysis of all losses of substance in both dental arches.

Identify patients’ expectations as clearly as possible. Some patients might think that it is obvious what
they want and that all clinicians proceed in the way. However, in the situations discussed here, treatment
may be primarily functional, but the aesthetic expectation may cover aspects related to the patient’s
2
psychological profile, with a quest for perfection that is, by definition, unattainable. Beware of
disappointments, therefore, since expectations can be particularly high. The active participation of
patients in the evaluation of aesthetic plans is often essential.
 Dental treatment plan check-list

Consider any functional and parafunctional disorders associated with the losses of substance observed.
Bruxism, mastication, phonation, sensitivity, temporomandibular joint dysfunction. These functional
3
disorders may be consecutive to the losses of substance observed, or concomitant. In all cases, it is
essential to take them into account to prevent treatment failure.

Multiple lesions may have caused a loss of vertical dimension or compensatory extrusion if they concern
canine teeth. In addition, erosion of the lingual surfaces of the maxillary incisor and canine sector
associated with involvement, to variable degrees, of the incisive edge of the mandibular incisor and
4
canine sector causes mandibular prognathism and a loss of guidance in lateral excursion movements.
Very often, loss of vertical dimension and compensatory extrusions are combined. Evaluate the role of
each process and then envisage how a functional dental anatomy can be restored in this context.

The aesthetic injury associated with these lesions in the anterior zones requires a global approach;
sometimes seeking previous photographic documents can serve as a reference. This is sometimes a
5 good opportunity to get patients involved in the development and subsequent validation of the aesthetic
plan. Complex rehabilitation of maxillary and sometimes mandibular anterior sectors requires the
organisation of sometimes long treatment sessions, with the management of intermediate stages.

The analysis of etiological factors and the patient’s ability to eliminate or at least reduce them is not
6 always easy. It is thus important to anticipate in the treatment plan the potential need for reintervention in
the event of an inevitable recurrence.

Erosion lesions are one of the types of non-caries lesions, alongside abrasive phenomena (generally
wear caused by traumatic brushing) and attrition phenomena (usually bruxism). In the presence of
7 extensive erosion lesions, it is essential to systematically assess the share of associated abrasion and/or
attrition phenomena before constructing the treatment plan. Even if the erosion phenomenon is
dominant, it is exceptional for it to be isolated in the presence of extensive lesions.

Although the lesions are erosion-related, it is necessary to assess the caries risk. In fact, several acidic
8 foods contain sugar (fizzy drinks, fruit juice, alcohol) and, in addition, the removal of certain acidic foods
from the diet, at our instigation, may cause a switch towards high-sugar foods.

Make contact and exchange information with the physicians involved in the patient’s care to coordinate
treatment: general practitioners, gastro-enterologist in the event of gastroesophageal reflux disease,
9 psychiatrist in the event of current eating disorder or other psychological disorders. Repeated vomiting
causes potassium loss, which can cause cardiac rhythm disturbances, requiring a few precautions
during anaesthesia with vasoconstrictors.

The duration and costs of treatment must be precisely assessed. It is necessary to include follow-up
10 costs, along with the costs of reinterventions, of variable significance depending on whether or not it is
possible to control etiological factors.

This construction may appear to be complex, but it avoids the occurrence of infinitely more complex
difficulties during treatment sessions.
TREATMENT PLANNING
Construction of the treatment strategy is a crucial step in the management of extensive erosive wear. Plan
treatment on the basis of the check-list:
◼ collection of additional tests, such as x-rays, moulds, occlusal analysis on a dental articulator in the
reference position chosen, functional tests, photos, blood tests, etc.;
◼ choice of materials and direct, indirect, combined techniques;
◼ organisation of intermediate steps, including delays and reassessment if necessary;
◼ validation of the aesthetic project;
◼ collection of particularly informed consent, which sometimes requires lots of explanations (aesthetic
expectation sometimes unattainable, assessment of costs);
◼ organisation of specific sessions in the event of modification of the intermaxillary relationship and/or the
vertical dimension;
◼ control visit after around 1 month to check functional aspects and make sure progress has been made
with etiological factors.

REFERRAL FOR DIAGNOSIS AND TREATMENT OF THE EATING DISORDER

◼ Discuss with the patient referral to a doctor (primary care physician or physician of the patient’s choice)
to confirm the diagnosis and, if necessary, put in place a multidisciplinary treatment plan.

◼ Consider the patient’s preferences in the context of a shared medical decision.

Resources available
◼ Directory of specialists (FFAB; FNA-TCA)
◼ French Anorexia and Bulimia helpline: 0810 037 037

© Haute Autorité de santé – 2019

1Bartlett D, Ganss C, Lussi A. Basic Erosive Wear Examination (BEWE): a new scoring system for scientific and clinical needs.
Clin Oral Investig 2008;12 Suppl 1:S65-8.

This document presents the main points of the best practice guidelines on "Bulimia nervosa and binge eating disorder – Detection and general
management information"
Clinical practice guidelines method – June 2019.
These recommendations and the scientific rationale can be consulted in full on www.has-sante.fr