At one point, Cram, a periodontist, had to put crowns on nearly all of the woman's teeth because her frequent purging had worn down the enamel.
For a few years, the woman seemed to gain control of her disorder -- bulimia nervosa.
Then Cram noticed the enamel under the crowns was again disappearing. She immediately notified the woman's doctor and therapist -- she was vomiting again.
"The mouth is often the first place that eating disorders show," says Cram, a gum disease specialist in Washington, D.C., and a consumer advisor for the American Dental Association.
"It's really important to have a joint relationship between the dentist, the therapist and the general practitioner," she says. "We can alert them to things they might not otherwise see, because, of course, they don't look in the mouth."
Eating disorders are among the most common mental health problems in the United States. Anorexia, or self-starvation, affects as many as one in 100 girls and young women, according to the American Psychiatric Association. The rate for bulimia, or purging after meals, is similarly high.
However, spotting these diseases can be exceedingly difficult, says Rita DiGioacchino DeBate, an assistant professor of health behavior and administration at the University of North Carolina at Charlotte.
People with eating disorders take great pains to hide or disguise their behavior. And until the disease reaches a severe stage, there may be few obvious physical signs. A woman with bulimia can still be overweight, DeBate says.
That's where dentists can help. Because the mouth is one of the first places to show evidence of eating disorders, dentists are in a perfect position to spot them.
A dry mouth, cracked lips, enlarged glands on the sides of the face and neck, hypersensitive teeth, bleeding gums and a sore throat are all signs of frequent vomiting, DeBate says.
Stomach acids can also lead to erosion of the enamel on the teeth, leaving the back of the top front teeth looking yellowed and pitted. One study found 38 percent of bulimics had evidence of teeth erosion or other symptoms, she says.
One symptom of the severe loss of body fat associated with anorexia is lanugo -- a fine, white, downy hair that the body grows to keep itself warm. You have to look closely to notice it, DeBate says. "Dentists are very close to the face and arms, meaning they can definitely identify it," she says.
However, many dental practitioners are reluctant to get involved with aspects of their patient's health that don't deal directly with the mouth, Debate says.
"Dentists and hygienists are not trained to talk to patients about this," DeBate says. "Some dental programs train dentists to fix the problems in the mouth, rather than look at the patient as a whole. The focus is on filling the cavities, rather than finding out what's causing the cavities."
DeBate recently received a $130,000 grant from the National Institute of Dental and Craniofacial Research to teach dentists to look for eating disorders and make referrals to therapists, nutritionists and others trained to treat the problem.
The first step of her research was a national survey to figure out how much dentists know about eating disorders. Preliminary results found 68 percent of dentists who responded to the survey had identified an eating disorder in a patient, but only 15 percent referred the patient to an expert who could treat the condition.
"There is some kind of disconnect there," DeBate says. "They are seeing it, yet they are not taking that step to refer them. They may believe it's not their role. If that's so, that's what we need to change."
The next step in her research, DeBate says, will be to test a health education program at 20 North Carolina dental practices. The program will help dentists identify signs of an eating disorder, approach the patient and make appropriate referrals.
Once the results of this study are in, DeBate plans to apply for more funding to make the program available to more dental practices throughout the United States.