The Effects of Purging on Oral Health

Purging, often associated with disordered eating behaviors like bulimia, involves self-induced vomiting to rid the body of food. This practice can severely damage oral health due to the acidic stomach contents repeatedly coming into contact with the teeth. This can lead to enamel erosion, tooth decay, gum disease and bad breath. Maintaining good oral hygiene and seeking professional dental care is essential for individuals who purge to mitigate the damage to their teeth and gums.

Impact of Self-Induced Vomiting on Oral health

Purging is a common compensatory behavior used by individuals with bulimia nervosa and other eating disorders. Compensatory behaviors include any disordered eating actions performed to make up for food intake or to reduce feelings of guilt or shame. Some of the most common purging methods are self-induced vomiting, diuretic misuse and laxative misuse.

Oral health has been linked to overall wellbeing and quality of life, with studies showing a connection between poor oral health and increased mortality.¹ While many complications related to bulimia nervosa and purging improve with treatment, some effects on oral health are irreversible. This highlights the importance of dental professionals, ENT (ear, nose and throat) specialists, and primary care doctors in identifying these issues, providing education and screening for eating disorders in patients who may be secretly struggling.

Purging & Eating Disorders

Bulimia nervosa

Bulimia nervosa is an eating disorder characterized by repeated episodes of binge eating, followed by compensatory behaviors like purging to prevent weight gain.² Individuals with this condition often have an intense fear of gaining weight and a distorted perception of their body, even though they typically maintain a normal weight.

Anorexia nervosa

Anorexia nervosa is an eating disorder defined by severely limited food intake resulting in markedly low body weight, accompanied by an intense fear of weight gain and a distorted view of one’s body size or shape.²

Purging disorder

Purging disorder involves recurrent purging behaviors – such as self-induced vomiting – without the presence of binge eating and without the individual being underweight.² While not a standalone diagnosis, the term is commonly used to describe a pattern of behavior that falls under the category of other specified feeding or eating disorder.

Oral & Dental Complications of Bulimia Nervosa

Enamel erosion (perimylolysis)

Chronic exposure to stomach acid can lead to dental erosion, one of the most common oral complications in people who purge through self-induced vomiting.³

Repeated exposure to vomit erodes the backside of the teeth, causing them to become weak, brittle and hypersensitive over time. When the enamel wears away and exposes the dentin, continued contact with vomitus can lead to:

• Infection
• Discoloration
• Pulp death of the teeth

Unfortunately, perimylolysis is irreversible once it develops. 

Chipmunk cheeks

Also known as parotid gland enlargement or sialadenosis, chipmunk cheeks are a common marker of self-induced vomiting.³ Sialadenosis usually occurs 3-4 days after purging has stopped and causes bilateral swelling of the parotid glands, sometimes affecting other salivary glands.

It is believed to occur due to either a backup of saliva that is no longer needed, cholinergic stimulation of the glands or hypertrophy of the glands to meet the demands of increased saliva production.

Gingivitis & periodontitis

Purging through self-induced vomiting and dry mouth can also lead to gum disease (gingivitis).⁴ Chronic irritation from exposure to stomach acid can cause inflammation, bleeding and pain in the gums.

If left untreated, it can develop into more severe and largely irreversible periodontal disease, known as periodontitis (degradation of the jawbone). Over time, pockets form around the gums, which can fill with plaque and bacteria, increasing a patient’s risk of infection, as well as causing tooth pain, loose teeth and tooth loss. 

Soft tissue damage

Vomiting pressure can cause blood vessels in the mouth to burst, leading the palate and tongue to appear orange-yellow. Inserting a hand or object into the mouth to induce vomiting can also cause redness, cuts, scratches or bleeding in the soft tissues of the mouth.

Xerostomia

Xerostomia (dry mouth) can be associated with reduced salivary flow from chronic dehydration from purging.

Pharyngitis

Pharyngitis is common in individuals who induce vomiting due to irritation of the throat caused by contact with stomach acid.³ This can lead to:³

• Hoarseness
• Cough
• Dysphagia

Hoarseness & cough

Repeated self-induced vomiting exposes the voice box and throat to stomach acid, irritating the tissue and causing hoarseness and coughing.

Cheilosis

Repeated purging and food restriction can cause deficiencies in nutrients that are crucial for skin and over time cause cheilosis, or cracks, sores and/or inflammation at the corners of the mouth.⁵

Bad breath

Poor enamel, gum disease, and cavities can all cause food particles and bacteria to become trapped in the teeth and gums, leading to halitosis, commonly known as bad breath.

Dry, cracked or inflamed lips

Chronic dehydration reduces saliva production and moisture of the lips.

Preventing & Treating Oral Complications of Eating Disorders

Cessation of vomiting

The best way to prevent or stop the progression of dental complications of self-induced vomiting is cessation of purging. Even with adequate dental care, oral complications are likely to progress if purging continues.

Fluoride treatments

Fluoride treatment can help strengthen teeth and reduce sensitivity for patients with eating disorders at risk for dental erosion and cavities.

Artificial saliva

Artificial saliva can be used to address dry mouth.

Basic solution rinses

Using water or a slightly basic solution containing baking soda or sodium fluoride after vomiting can help neutralize stomach acid and protect tooth surfaces.

Restorative dental work

For advanced dental complications, restorative dental work may be necessary. However, patients should have stabilized eating behaviors. Common restorative procedures include:

• Dental fillings
• Dental crowns
• Veneers
• Inlays

Are Dental Complications Permanent?

Some complications, like dental erosion and periodontitis, are permanent. However, most other complications can be reversed with cessation of purging.

Get Help for an Eating Disorder

Dental and oral health issues from an eating disorder can be painful and uncomfortable. With the right support and treatment, recovery is possible, and steps can be taken to protect your teeth and overall oral health.

References

1. Vogtmann, E., Etemadi, A., Kamangar, F., Islami, F., Roshandel, G., Poustchi, H., Pourshams, A., Khoshnia, M., Gharravi, A., Brennan, P. J., Boffetta, P., Dawsey, S. M., Malekzadeh, R., & Abnet, C. C. (2017). Oral health and mortality in the Golestan Cohort Study. International Journal of Epidemiology, 46(6), 2028–2035. https://doi.org/10.1093/ije/dyx056
2. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: APA.
3. Nitsch, A., Dlugosz, H., Gibson, D., & Mehler, P. S. (2021). Medical complications of bulimia nervosa. Cleveland Clinic Journal of Medicine, 88(6), 333–343. https://www.acute.org/medical-complications-bulimia-nervosa
4. Spigset, O. (1991). Oral symptoms in bulimia nervosa A survey of 34 cases. Acta Odontologica Scandinavica, 49(6), 335–339. https://doi.org/10.3109/00016359109005929
5. Mehler, P. S., & Andersen, A. E. (2017, November 29). Eating Disorders: A Guide to Medical Care and Complications (third edition). Johns Hopkins University Press