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November 28, 2007

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Bulimic Dental Patients & Obesity

By Rhonda R. Savage, DDS

Human beings have always had a complicated relationship with food. Staying alive from day to day requires our bodies to keep a lot of systems running just so, but most of them — circulatory, respiratory, neurological, and endocrine — operate automatically. Eating is different. It's a voluntary thing. With obesity and bulimia, patients don't just overeat. There are many complex issues that arise with these complex populations of patients. This article will discuss obesity and bulimia, two very different issues that can be closely related and may pertain to a certain type of patient in your dental practice. Both obesity and dieting are risk factors for bulimia. First, let's talk about obesity, then we'll discuss bulimia. Finally, I will present a case study about a female patient who suffered from both conditions.

Early diagnosis, referral, and treatment of eating disorders significantly increase the chance of recovery for these patients. Despite this, only one in 10 receives treatment. Identifying these disorders may be difficult as many people frequently hide or deny their behaviors. The rate of anorexia and bulimia nervosa in the United States is less than 7 percent of the population, and this number remains relatively constant. In contrast to the rate of eating disorders, the rate of obesity in the United States has tripled to more than 30 percent of all Americans.

What normally happens during hunger while you eat?

As you eat, your stomach and intestines stretch, sending nerve impulses to the brain that quiet appetite. It's a slow process. Your stomach may say stop eating, but your brain won't hear the message for several minutes.

Hunger isn't just in your head. When your stomach is empty, it contracts, sending signals to the brain along the vagus nerve. The effect is that hunger affects both voluntary and involuntary physical systems. You can ignore the contractions, but a host of other signals will soon take over.

The role of senses and sight of food can stimulate your appetite. The body produces a hormone called ghrelin, which is produced in the stomach. This hormone sends strong feelings of hunger to the brain. It's rising ghrelin concentrations that account for hunger as mealtime approaches. The more ghrelin, the more hunger you feel. Gastric bypass surgery reduces ghrelin production, helping obese people feel full longer.

There are other hormones that participate in the hunger cycle, including leptin, PYY, and GLP-1. The role of leptin is to act as the body's long-term regulator. Produced in the fat cells, it tells the brain that the body's fat reserves are sufficient by signaling the hypothalamus and dampening some appetite signals. Most obese patients have plenty of leptin, they just don't respond to its signal normally. The role of the hormones PPY and GLP-1 is to repeat the stop command for eating and reinforce the stomach to stop pushing food along until what's already in the digestive system is broken down further. These hormones are produced in the small intestine and are responsible for the full feeling that can last for hours after eating.

Besides the naturally occurring regulatory hormones, certain receptors and peptides play a role in hunger. PPARs are receptors that regulate energy consumption in cells. After we eat, the system gets revved up. Nutrients that are left over are stored as fat. The more active the PPAR system, the more fat you'll burn. The PPARs of obese people may be working too slowly. In this complex hunger system, a peptide called cholecystokinin, or CCK, is also involved in hunger regulation. CCK travels along sensory nerves to tell the brain more emphatically that the meal is over.

The causes leading to obesity can be many. Obesity can be related to endocrine disorders or medication. Illnesses that necessitate medication related to obesity include hypertension, diabetes, hyperlipidemia, heart disease, obstructive lung disease, hyperuricemia, and degenerative spine disease. Drug and sweet addiction can also be factors relating to the development of obesity. But often, the specific reason for obesity is not understood. Besides the possible malfunctioning hormonal, peptide, and receptors issues, obesity may be caused by the malfunction of the satiety center in the hypothalamus, which is not well understood.

What operations treat symptoms of overeating that lead to obesity?

The two most basic approaches are gastric bypass surgery and laparoscopic gastric banding.

Gastric bypass is the most effective surgery for morbidly obese patients, but the severe, potentially life-threatening complications must be seriously considered. Gastric bypass surgery can cause a general malabsorption created by the short bowel syndrome. The complications include hepatic failure, late development of cirrhosis, and a host of metabolic deficiencies.

The LAP-BAND® procedure includes an adjustable band that is placed laparoscopically around the very proximal stomach, which allows control of the outer diameter and enables weight loss as a result of limited food intake. The LAP-BAND procedure allows a significantly shorter hospital stay, earlier return to work, and fewer wound infections and hernia problems.

Both surgical procedures can aid in dramatic weight reduction, but unless underlying psychological issues are resolved, there can be an increase in the risk of eating disorders, especially bulimia.

Why are obesity and a history of dieting risk factors for bulimia?

Studies show that cases of bulimia typically occur in industrialized countries where food is plentiful and a preoccupation with thinness in women is apparent. People with bulimia have eating binges during or immediately following diets. Psychological factors and a family history of eating disorders also appear to be related to the development of bulimia. Depression, affective disorders, substance abuse, and a history of sexual abuse may increase the chances of developing bulimia.

Many young women with eating disorders suffer from depression and often anxiety. Gene research suggests that these two states may share a single set of genes. There may be links also between anorexia nervosa, obsessive-compulsive behavior, anxiety disorders, and depression, all of which persist long after an eating disorder is treated. Michael Strober, director of UCLA's Eating Disorder Program, states that bulimic and anorexic patients are considered recovered when they maintain a healthy weight and no longer count calories, binge, purge, or manically exercise; yet even years later, these recovered patients will show abnormally high rates of anxiety and obsessive thinking, especially perfectionism.

Assessment and diagnosis of bulimia may be difficult given that many people with this condition appear to be of normal weight and tend to avoid disclosing their binging and purging behaviors. Treatment of bulimia includes nutritional counseling, medications, and psychotherapy. The most commonly prescribed medications for individuals with bulimia are antidepressants. In some cases, antiemetics are prescribed short-term at the onset of treatment to reduce the stimuli to vomit.

The term bulimia is derived from the Greek word for "ox hunger" and depicts the extreme nature of binge eating. In her book "Gaining," Aimee Liu recalls observing girls who would load up on grilled cheese sandwiches or pizza at lunch, then scurry to the lavatory before the next class, and how they developed chipmunk cheeks, blotchy skin, and dull hair. They sounded hoarse and had teeth as stained as long-term smokers.

In dental offices, we are in a position to aid in early diagnosis and refer patients for treatment. Oral findings vary in severity with the length of time a person has had the disorder, the degree and frequency of pathologic eating behaviors, diet, and oral hygiene habits. The most common oral manifestations affect the dentition, salivary glands, periodontium, and oral mucosa. The most common effect of bulimia is enamel erosion associated with chronic regurgitation of gastric contents. The enamel erosion is typically seen on the palatal surfaces of the maxillary premolars and anterior teeth, usually appearing as a smooth, glassy surface. The margins of restorations on posterior teeth may appear to be floating. Patients often complain of temperature sensitivity and occlusal changes. With chronic, long-term bulimia, patients are at risk for gastroesophogeal reflux disease (GERD) and possible tearing of the esophagus.

In my practice, I use GERD as a reason to open the discussion of the possibility of an eating disorder. This is a sensitive question to broach with patients, and asking them about a history of acid reflux is a more delicate way to begin questioning patients. The primary goal is to reduce or eliminate the binge eating and purging behavior. This includes nutritional counseling, psychological counseling, and medication management strategies.

Case study

This 60-year-old patient presented with chipped, worn-down teeth, multiple restorations, and little lingual enamel. She had recently lost more than 100 pounds following a laparoscopic banding procedure and wanted to improve her smile. She also had a face lift to remove excessive skin and a blepharoplasty (eyelid reduction).

We discussed treatment options, and she chose Lava crowns for the strength needed to resist her clenching and grinding habits. I checked the shape of the crowns and their relationship to tissues with a tissue model, similar to the tissue models used with implant restorations. This way, I can be sure the contacts are adequate to support the papillae and prevent the creation of a black triangle. The patient would like to restore her other teeth eventually, especially the lower anteriors, but will be treated in phases. She has made significant changes in her life, which have created balance, improved her self-esteem, and boosted her happiness. She is happy with her smile after the crowns were seated.

What's happened to the human species?

Postindustrial humans have become soft, sedentary, and overfed — 67 percent of the U.S. population is either overweight or obese, including about 17 percent of children ages 6 to 19.

Obesity tends to be a chronic condition, such as hypertension and diabetes, influenced by genetic, metabolic, and environmental factors. The pathogenesis of morbid obesity involves more than a lack of willpower or a sedentary lifestyle. As health care providers, we must be concerned because obesity contributes to coronary heart disease, hypertension, type 2 diabetes mellitus, hyperlipidemia, degenerative joint disease, obstructive sleep apnea, and many types of cancer.

The ability of a patient to keep off more than 30 pounds for more than a year is rare, as shown in the National Weight Control Registry, which tracks the habits of some 5,000 successful maintainers. Only one-fifth of dieters with a history of obesity sustain a weight loss of 10 percent of their body weight for a year or more. The best predictors of who will keep the weight off are patients who exercise for an hour or more a day. Weight control, weight reduction, and eating disorders weigh heavily among health care providers and should be a special concern of dentists. We may provide nutritional counseling and motivation for weight loss. As dentists, we also have the possibility of early diagnosis and intervention with eating disorders, yet studies show that dentists and hygienists are often unprepared to deal with the complex issues related to eating disorders.

People with eating disorders have the highest mortality rate among any groups affiliated with mental illness. Twenty percent of people who suffer from eating disorders will die prematurely from complications related to their disorders, including suicide and heart problems. Failure by dental care providers to identify these oral manifestations may lead to serious systemic problems and irreversible damage to the oral cavity, in addition to reducing the likelihood of early treatment and case management. All dentists should discuss these health issues with patients. With a caring and understanding approach, dentists can counsel patients on nutrition and the relationship of systemic disease to oral health.

Dr. Savage is an affiliate clinical instructor at the University of Washington School of Dentistry and is in private general practice in Gig Harbor, Wash. You may contact Dr. Savage at rsavage@harbornet.com.

References available upon request.

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