Oral complications of self-induced vomiting: beyond benign sialometaplasia

Chronic gastric reflux related to self-induced vomiting (SIV) in eating disorders exposes the oral mucosa to repeated chemical and mechanical aggressions. Among these complications, necrotizing sialometaplasia (NS) of the hard palate is classically described as a benign and self-resolving lesion, generally not requiring oral surgery.

The objective of this case report is to document an atypical and severe progression of this pathology in a female patient in her twenties, where the initial lesion progressed to an irreversible palato-nasal fistula. The study aims to identify the clinical variables that hindered the spontaneous healing usually expected.

The central hypothesis suggests that the persistence of local irritants — notably continued vomiting, smoking, and the administration of local anaesthesia during dental care — can alter the prognosis of NS. This case illustrates how an initially benign pathology can, under the influence of persistent pathological behaviours, lead to major structural sequelae requiring surgical repair and multidisciplinary psychiatric and dental management.

Case report methodology

This work is a clinical case report detailing a rare complication of necrotizing sialometaplasia (NS) in a patient with eating disorders. The study documents the atypical progression of a usually benign pathology towards an irreversible lesion.

The follow-up protocol and sample characteristics are as follows:

• Subject: A woman in her twenties with a long-standing history of eating disorders, characterized by habitual self-induced vomiting (SIV).
• Clinical observation: Follow-up of an initial SN lesion on the hard palate. The authors documented the failure of spontaneous healing and the pathological progression towards a palatonasal fistula.
• Risk factor assessment: Clinical analysis focused on factors contributing to persistent local irritation of palatal tissues, including ongoing vomiting, the patient's smoking habit, and the administration of local anesthesia during concomitant dental care.
• Management: A multidisciplinary strategy integrating psychiatric and dental follow-up was applied throughout the clinical course.
• Procedure: Due to the lack of spontaneous closure of the fistula, a final surgical repair procedure was performed.

Clinical observations and evolution of the lesion

The study reports the case of a female patient in her twenties with a chronic history of self-induced vomiting (SIV) related to an eating disorder. Initially diagnosed with necrotizing sialometaplasia (NS) of the hard palate, the clinical progression diverged from the benign course typically observed in this pathology.

Persistence and aggravation factors

The qualitative analysis of the patient's journey identified several contributing factors that maintained local irritation and hindered tissue revascularization:

• Persistence of chemical aggressions: Continued induced vomiting maintained constant acid exposure on the already weakened palatal tissues.
• Smoking: Identified as an aggravating factor for local ischemia.
• Iatrogenesis: Performing dental procedures requiring local anesthesia (potentially containing vasoconstrictors) has been noted as an additional risk factor for tissue necrosis.

Therapeutic outcome

Unlike classic cases of necrotizing sialometaplasia where monitoring is the rule, the severity of the lesion and its irreversible nature made spontaneous closure of the fistula impossible. A multidisciplinary approach, combining psychiatry and dental care, was maintained throughout the follow-up, ultimately leading to surgical repair of the palato-nasal fistula to restore the patient's quality of life.

Clinical analysis and atypical progression of NS

This case report illustrates a major deviation from the usual clinical course of necrotizing sialometaplasia (NS). While the literature classically describes this pathology as a benign and self-resolving lesion, the results of this study show that continuous exposure to self-induced vomiting (SIV), coupled with smoking and repeated local anesthesia, can lead to full-thickness necrosis. The clinical significance is major: in patients suffering from eating disorders (ED), NS can progress to an irreversible palato-nasal fistula (PNF), requiring extensive surgical intervention.

Limits and comparison with the literature

The study reports a single case (n=1), which limits the generalization of the prevalence of this complication. However, it contrasts with conventional data by highlighting that the prognosis depends directly on the control of irritative stimuli. Unlike cases of spontaneously resolving SN, the persistence of chemical (gastric acid) and mechanical aggressions here prevented any healing, transforming a local lesion into a structural loss of substance altering the quality of life.

Implications for daily practice

For the dental surgeon, the presence of an SN in a female patient in her twenties with a history of ED is not to be overlooked as a mere clinical curiosity. These findings suggest that passive monitoring may be insufficient. The practical implication is the need for immediate coordination with psychiatric services to attempt to stabilize purging behaviors, alongside dental management. The persistence of the lesion beyond normal healing times should raise concerns about progression toward a fistula, radically changing the treatment plan toward a reconstructive approach.

Study summary

This case report describes a female patient in her twenties whose palatal necrotizing sialometaplasia (NS), induced by chronic vomiting, exceptionally progressed into an irreversible palato-nasal fistula. Persistent local irritation — including smoking and local anesthesia injections — hindered the usual spontaneous healing, necessitating a final reconstructive oral surgery intervention.

In concrete terms, for the practitioner:

• Diagnostic vigilance: When faced with a palatal lesion in a young patient, suspect an eating disorder (SIV); SN is not always self-resolving and can lead to a transfixing loss of substance.
• Iatrogenic caution: Limit local anesthesia injections in an area suspected of SN, as additional iatrogenic ischemia may precipitate deep tissue necrosis and fistula formation.
• Success condition: The success of a surgical repair depends on prior multidisciplinary management aimed at stopping chemical irritation (vomiting), otherwise recurrence or healing failure may occur.

Technical lexicon of the study

Necrotizing sialometaplasia (NS): Benign inflammatory lesion of the minor salivary glands, classically self-limiting. Although it can clinically simulate a malignant tumor, it generally does not require surgical intervention, except in cases of atypical progression.

Self-induced vomiting (SIV): A voluntary act leading to repeated exposure of the oral cavity to chemical (gastric acid) and mechanical insults, constituting a major etiological factor for palatal tissue lesions.

Palato-nasal fistula: Pathological communication between the oral cavity and the nasal cavity. In this clinical case, it represents a severe and irreversible complication resulting from necrotizing sialometaplasia that did not heal spontaneously.

Eating disorders: Psychiatric pathologies characterized by abnormal eating behaviors (such as chronic SIV), requiring multidisciplinary management to limit systemic and oral repercussions.

Hard palate: Anatomical structure of the oral vault rich in minor salivary glands, particularly vulnerable to prolonged local irritation and the primary site of reported necrotizing sialometaplasia.

Psychoeducation: Component of the multidisciplinary treatment aimed at informing the patient about the hidden risks and complications of their pathology (here irreversible oral lesions) in order to improve the therapeutic alliance and clinical results.

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