Dental CSI: A Miscommunication Journey With a Patient With an Eating Disorder

Bulimia is a modern day disease that affects an important percentage of our population - perhaps a higher percentage than we care to recognize. Media outlets consistently and increasingly display what is the norm when it comes to what should be the “ideal” body size and weight for a person. This so-called “Selfie Era” also contributes a fair bit to self-awareness and the need to be accepted in today’s fashion standards. This quickly translates to body downsizing and becoming fit for the much-needed social media validation.

I’d like to share the story of a young lady who came to see us a few months ago in search of a “smile makeover,” (Fig 1) as she did not like her existing smile and teeth at all. She felt that the incisal edges were too thin and wanted larger/longer looking teeth.

She even brought a number of examples taken from top model pictures from fashion magazines to show us her expectations.

Typically when we hear such a complaint, we get excited, because chances are, this may very well be a patient that will appreciate our craftsmanship and attention to detail and may also very well become our raving fan. They may then become an ambassador of our good work and will not stop promoting our expertise.

She also mentioned that the wanted her gleaming new smile ready for her wedding, which was two months down the road.

Anyhow, as with any other patient that comes in interested in an esthetic workup, we need to have a thorough documentation comprised of clinical pictures, radiographs and study casts. As we examined her clinically and carefully reviewed our set of photographs, we could unequivocally see large erosive lesions in the palatal aspect of her maxillary incisors, (Fig 3) which had even extended to the first bicuspid. Her lower arch appeared pretty intact (Fig 4), and radiographically everything looked within normal limits (Fig 5).

The pattern and location of these lesions is typically caused by a condition known as intrinsic erosion. While intrinsic erosion is caused by hydrochloric acid, the actual differential diagnosis lies between either GERD (Gastroesophageal reflux disease) or bulimia (eating disorder associated with self-induced vomiting).

So at this point it is important to be extremely careful when talking to patients about the potential diagnosis, as it is usually a very delicate subject. Many patients may not feel comfortable talking about it, as in many instances, this type of behavior is considered a modern day “taboo.”

In a previous Digest article I wrote last year, I went through the concept of “the buyer’s journey,” which is a marketing tool that walks the potential buyer (or patient, in this case) though three distinctive stops before buying:

• Awareness stage
• Consideration stage
• Decision stage

Sticking to this journey as our way of communicating with the patient, we started through the awareness stage, talking to the patient strictly about the nature of the lesions found in the palatal aspects of her teeth. Now, she was not aware of the extent of these lesions, as they are in a non-apparent zone in the back of the teeth, so she seemed pretty engaged and interested in the conversation. We also showed her the Spear Patient Education video on erosion, which does a great job highlighting the condition to the patient in the most lay terms possible. Once she saw the video, we showed her side-by-side images of her condition with what she saw in the video (Fig 6).

I was as non-confrontational as I could be, just cautioning her on the potential outcome should we not address these lesions; the patient agreed to have a consultation with a GI specialist to further explore the potential GI reflux etiology of the erosion. I did ask if she was aware of any other potential reason the HCl could be causing such damage in her teeth.

At any rate, she left our office pretty committed to go and visit the GI specialist and said she’d be back with us the following week to resume our discussion and begin treatment. Sure enough, she failed to her scheduled appointment and did not call us back. We did not hear from her until a month later, when she called desperately wanting to talk to me, as she was in a lot of pain.

This was over the holiday season, so I was not in town but she managed to text me on my cell phone. I decided to call her and talked to her.

She was distraught - very apologetically, she admitted that she went somewhere else for her dental treatment, had quite an extensive treatment done and was now in excruciating pain. She also mentioned that she was in a very critical emotional situation: she canceled her wedding plans, broke up with her boyfriend and finally admitted to having eating disorders. She has been bulimic for nearly two decades and is now ready for help.

When she came to see us, we discovered that the other dentist had placed full coverage restorations, from second bicuspid to second bicuspid in the upper arch, and veneers and crowns (Fig 7)  from second bicuspid to second bicuspid in the mandible.

Two things truly bothered me about this incident:

• The aggressive nature of the treatment she received.
• The fact that we were not able to initially retain the patient.

A total of 20 (Fig 8) restorations were placed, and there was really no need to restore full coverage.

Because there had been some compensatory eruption as a consequence of the chronic erosion, and the vertical dimension was not restored in order to create vertical space, the dentist decided to prep those erosive lesions even further in order to create restorative space for the ceramics. Therefore, the patient was in pain, likely due to irreversible pulpitis from overpreparing those teeth.

She told me that she realized she went to the wrong dental office and wanted us to take her back as a patient after all that damage was done. She finally mentioned that the reason why she initially went somewhere else was that she felt that I was a detective and was very close to discovering her secret of 20 years. Since I was her parents’ dentist, she was afraid I would talk to them about her condition.

You can imagine how all this made me feel; but the true take-home message for me was that whenever we see intrinsic erosion on palatal surfaces of maxillary teeth, we have to be “extra careful” in our communication with our patients, put on our “empathic educator’s hat” and do our best to carefully and caringly caution patients on two fronts:

1. The consequences of inaction.
2. The consequence of going through an invasive restorative approach.

(Click this link for more dentistry articles by Dr. Ricardo Mitrani.)

Ricardo Mitrani, D.D.S., M.S.D., Spear Faculty and Contributing Author