The Pattern of Wear Told Us Something She Had Not Said

Quick answer: Dentists often see the physical signs of repeated vomiting before anyone else does, because the damage is on surfaces nobody else looks at. How that conversation is handled determines whether the person gets help or does not come back.

The call

She came about sensitivity and a chipped front tooth, and gave every impression of wanting the appointment to be brief.

A woman in her mid-twenties, from Beit Shemesh. This story is written with more distance than the others, deliberately.

What we found

Erosion of the palatal surfaces of the upper front teeth — the inner side, facing the tongue — with enamel thinned to the point of translucency and dentine exposed across broad areas. The biting edges were chipped and thinned.

The lower teeth were comparatively spared.

Cupping on the biting surfaces of the upper molars, with two restorations standing proud.

The distribution matters. Acid arriving from the stomach pools against the palatal surfaces of the upper teeth; the tongue and the saliva in the floor of the mouth partly protect the lower arch. That pattern points to intrinsic acid, and there are two principal causes: reflux, or repeated vomiting.

Reflux was covered in another of these stories and produces a similar picture. The features that pointed away from it here were the severity relative to her age, the absence of any reflux symptoms on direct questioning, mild enlargement of the parotid glands on both sides, and a small area of callus on the back of one hand.

None of those is proof. Together they form a picture, and the honest position is that a dentist can recognise a pattern and cannot diagnose an eating disorder.

What we did

The conversation, which is the whole of this case.

We did it with the chair upright, at the end of the appointment, with her dressed and sitting normally rather than lying back — the physical arrangement matters more than people expect. The nurse left.

What was said was close to this: that the wear pattern on the inner surfaces was the kind caused by stomach acid, that this happens with reflux and it also happens with vomiting, and that we were not asking her to explain it — only telling her what we could see and that we could help protect her teeth either way.

Then silence, which is the hardest part and the most important.

She did not disclose anything at that appointment. She booked another.

At the second appointment, three weeks later, she did.

What we did not do, and each of these matters:

• Did not ask "are you making yourself sick", which forces a denial that then has to be maintained.
• Did not express shock, concern or disappointment.
• Did not tell her to stop, which is not within anyone's gift and communicates that the problem is understood as a choice.
• Did not contact anyone without her knowledge. She was an adult; confidentiality applied.
• Did not make treatment conditional on her getting help.

What we did do:

• Gave her the information for support services and for her kupah's route to an eating disorder service, in writing, without requiring her to do anything with it.
• Offered to write a referral letter when she was ready, which she accepted at the third appointment.
• Protected the teeth in the meantime, which is the dental job and does not depend on the underlying problem being resolved first.

Protective measures, which are specific and worth stating because they are counterintuitive:

• Do not brush after vomiting. Enamel is acid-softened and brushing removes it. Rinse with water, or a bicarbonate solution to neutralise, and wait an hour.
• High-fluoride toothpaste, and fluoride varnish every three months.
• A soft night guard worn during episodes was discussed and she declined, which was her choice.
• No restorative work yet. Rebuilding worn surfaces while acid exposure continues means the restorations fail and the patient concludes that treatment does not work.

The outcome

She was referred, at her request, at four months. Her recovery is not this story's to tell.

Dentally: casts at twelve and twenty-four months showed the wear had stopped. At that point we rebuilt the palatal surfaces and edges of the six upper front teeth in composite, and treated the sensitivity.

She has attended every six months for four years.

What to do if this happens to you

1. Do not brush after vomiting. Rinse with water or bicarbonate and wait an hour.
2. Use high-fluoride toothpaste and ask for regular varnish.
3. Tell your dentist, if you can. They have seen it before and it changes what they can do to help.
4. Expect confidentiality. For an adult, nothing is disclosed without consent.
5. Ask for restorative work to wait until the erosion has stopped. It lasts longer that way.
6. Ask for a referral letter whenever you are ready, not before.

Concerned about tooth wear? Ramat Beit Shemesh Urgent Dental Care treats this confidentially and without judgement. 055-985-8845 · WhatsApp https://wa.me/972559858845 · Harav Kook 28/1, Beit Shemesh

This is a composite clinical story. It reflects a presentation we see regularly in Beit Shemesh and Ramat Beit Shemesh; the name and details are illustrative and are not those of a real patient.