By Sarah-Ashley Robbins, MD and Rachel Barone, DDS, FAGD, FICOI
In addition to an increased incidence of dental decay and disease, recurrent self-induced vomiting from either anorexia or bulimia nervosa can lead to multiple medical complications of the mouth and throat. The muscles of the upper esophageal sphincter, which acts as a gateway to the esophagus, become dysfunctional with chronic purging which more easily allows stomach acid and enzymes to reach the throat and mouth. This type of reflux is known as laryngopharyngeal reflux (LPR), and commonly causes symptoms such as hoarseness, pain/difficulty swallowing, chronic cough, frequent throat clearing, repeated sore throats, and increased mucous production. In addition, the acid left unchecked by your body's protective barriers can negatively affect the teeth and sinuses. Your dentist will likely see signs of LPR as eroded enamel on the inside of the teeth, and, for some patients, difficulty swallowing and breathing when laid back in the dental chair during treatment. Fortunately, there are treatments for LPR to utilize while a patient is treating their eating disorder. These treatments include lifestyle modifications (don’t worry it doesn’t involve restriction of food groups!), proton pump inhibitors, H2 blockers, and antacids. It is important to talk to your doctor about LPR as the treatment can vary depending on the clinical situation.
If you suffer from bulimia, you may also experience an enlarged parotid salivary gland, also called parotid hypertrophy. Every human has parotid glands in our cheeks which produce saliva to moisten the mouth, help us swallow food, and supply an enzyme called amylase that helps digest some starches in the mouth. If you chronically purge via vomiting, the parotid glands may become enlarged. This condition is typically painless but can become permanent even after you have been long recovered from an eating disorder involving self-induced vomiting. Interestingly, when you stop purging--whether in a treatment program or while working with an outpatient team--the parotids can become more enlarged and very painful, a condition known as acute sialadenitis. This can make cessation of purging very challenging because not only can it cause physical pain, but it also can make the cheeks appear greatly enlarged, triggering body dysmorphia and psychological distress in some patients. The symptoms of acute sialadenitis can be mitigated with a variety of treatment options:
1. You can use tart candies like lemon drops to help increase saliva production, which often helps decompress the parotid glands.
2. You can use warm compresses over the cheeks.
3. Your physician can schedule over-the-counter or prescription strength anti-inflammatories (NSAIDs) for several days or weeks for pain management.
The important thing to know is that the acute sialadenitis will eventually resolve but the days to weeks some patients have to wait for full resolution can lead some patients to engage in other eating disorder behaviors or restart purging to relieve their psychological distress. It is vitally important to work with a supportive multidisciplinary team, especially if this has been a barrier for you to recover from your eating disorder.
Whether or not you are actively seeking treatment for a purging eating disorder, it’s important to be mindful of the impacts purging has on the oral cavity. Changing some home care practices can help protect your teeth if you suffer from a purging eating disorder. For starters, do not brush your teeth immediately after purging. Instead, rinse your mouth with water and wait 20 minutes before brushing to let the acidity of your mouth neutralize. Also, use a soft bristled toothbrush and non-abrasive toothpaste, as both can minimize further damage to already weakened enamel. Also, it's imperative to continue your routine dental hygiene visits. Even if you are not experiencing pain or breakage of your teeth, it’s beneficial to have your oral health thoroughly checked on a regular basis. So many facets of dental disease don’t cause symptoms until they are more advanced, and a routine oral evaluation can help catch problems early so if something does develop it can be addressed in a more conservative way. In addition to your physician and healthcare team, your hygienist and dentist are valuable partners in helping you protect your teeth throughout your lifetime, and want to help in any way possible to keep you and your mouth healthy.