Beware of bulimia and tooth wear

With dentists ideally placed to recognise eating disorders, to raise awareness of the effect on the dentition and to mark Eating Disorders Awareness Week, taking place from 25 February to 3 March 2019, Professor Andrew Eder considers the oral health challenges and offers preventive advice.

According to the UK eating disorders charity BEAT, around 1.25 million people in the UK have an eating disorder, with about 40% of those suffering with bulimia (, 2018). Yet, in a Yougov survey conducted for Eating Disorders Awareness Week in 2018, more than one in three adults in the UK who took part could not name any signs or symptoms of eating disorders (, 2018).

To give it its full medical name, bulimia nervosa is defined by The Oxford Dictionary of Dentistry as: ‘An eating disorder in which large amounts of food are eaten followed by self-induced vomiting.’

The definition continues: ‘The vomiting can lead to severe dental erosion. Patients are often fanatical about oral hygiene, which can lead to toothbrush abrasion and gingival recession.’

Oral signs and symptoms

Therefore, it is clearly important the dental profession is able to recognise the signs and symptoms of bulimia in their patients.

Extended periods of intentional vomiting causes acid erosion, which may result in:

  • The teeth becoming rounded, smooth and shiny and losing their surface characteristics
  • Incisal edges appearing translucent
  • Cupping forms in the dentine
  • Shallow and rounded cervical lesions
  • Restorations standing proud of the surrounding tooth tissue, because they tend to be unaffected by erosion.

In addition, abrasion such as that potentially caused by overzealous toothbrushing may manifest as:

  • Teeth becoming less white as some of the outer surface is lost
  • Chewing surfaces wearing flat and taking on a shiny, pitted appearance
  • Restorations such as crowns and bridges may stand proud of the natural teeth (as is also found with erosion).

Alongside this, attrition as a result of tooth grinding may present with:

  • Front teeth becoming short, sharp or chipped
  • Back teeth becoming shorter and opposing chewing surfaces wearing flat
  • Failing and fractured restorations.

This brings up an interesting point that tooth wear is multi-factorial – dentists will not see the dentition affected just by erosion, abrasion or attrition alone or, indeed, any other recognised mechanism of tooth surface loss in isolation. This then requires a multi-factorial clinical response and, since we are dealing with a mental health disorder, dentists and their teams must approach the issue with great sensitivity.

Taking preventive action

Bulimia sufferers do tend to react with embarrassment and deny there is a problem when the issue is raised with them, so if there is a concern that needs to be addressed in dental practice, try to make them feel at ease beforehand.

You can do this, in part, by telling them you have time to talk things through, communicating on their level and asking questions in a non-judgmental manner aimed at encouraging the patient to identify the cause of their oral health problems. It may help if you share your examination findings with the patient and explain how their symptoms are linked.

At this stage, it is not about offering treatment but rather preventive advice. It may be helpful to:

  • Issue a fluoride rinse or gel and prescribe a high-fluoride toothpaste for daily use
  • Advise the patient not to brush immediately after vomiting or consuming acidic foodstuffs, and to rinse with a fluoridated mouthwash and chew sugar-free, xylitol-sweetened gum afterwards.

As for abrasion caused by a rough brushing technique, an important preventive message to share with patients is the need for gentle but effective brushing. Experience has shown that many people mistake brushing hard for brushing well. If properly explained to a bulimic patient, they might be able to alter their brushing habits, as long as they are reassured their oral health will not suffer – and, in fact, improve. It may also be appropriate for the dentist or hygienist to demonstrate the best brushing technique for the patient, and to recommend the use of a soft toothbrush and non-abrasive toothpaste.

In addition, extra protection may be provided via calcium and phosphate ions, to help restore the mineral balance, neutralise acid in the mouth and increase salivary flow.

Protecting the remaining dentition

Of course, getting a bulimic patient to take preventive action is easier said than done, given the nature of the disease. It may also, therefore, be necessary to protect the remaining dentition, for example direct application of a glass ionomer or composite to sensitive areas, an occlusal guard to protect the teeth during purging, and/or an alkali or fluoride gel placed within the fitting surface of the guard to neutralise any acid pooling.

Once any treatment has been completed, it is important that the patient attends for regular check-ups. This will allow monitoring of the rate of wear with models and photographs if the patient is agreeable and, when appropriate, further guidance and encouragement can be provided, together with any adjustments to lifestyle being made.

Much of what a bulimic patient goes through is, of course, beyond the scope of the dental professional and they may already be under the care of various agencies. Consequently, it may be sensible (with the patient’s consent) to contact their GP or other healthcare professional overseeing their care before beginning any course of treatment. This will facilitate a team approach, to help decide upon a course of action that will offer the best possible outcomes given the patient’s circumstances.

The London Tooth Wear Centre offers an evidence-based and comprehensive approach to managing tooth wear, using the latest clinical techniques and a holistic approach in a professional and friendly environment. If you have any concerns about your patient’s tooth wear, please visit, email or call 020 7486 7180.

References (2018) accessed 21 December 2018 (2018) accessed 21 December 2018

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