Pica

Amanda Reau

June 27, 2017

Dental Hygiene III

 Pica is defined as a pattern of consuming nonfood materials such as soil, clay, hair, etc.

for a period of at least one month. This does not include exploration of children under the age of

two that may place items in their mouth. Pica is the most common eating disorder found in those

with developmental disabilities. According to the DSM-5, The Diagnostic and Statistical Manual

of Mental Disorders, for someone to be diagnosed with pica they must fit the following criteria:

eating of “nonnutritive substances” for greater than one month, eating these substances is not in

line with their developmental level, consuming the products is not culturally or socially

acceptable, and severe enough to require independent attention if in connection with another

mental disorder or medical condition. (Frese)

Clay consumption dates back to 10 BC. It was then consumed for medicinal reasons. It is

unknown who first discovered pica, however, the consumption of nonfood materials as a

“disorder” dates back to 1800 BC, with the Chinese, Egyptians, and Sumerians. The

consumption of clay was also seen with the Greeks and Romans in the 13th century. The first

medical text to include pica was in connection to pregnant women and children, seen in 1563.

Some cultures still consume various nonnutritive items as part of healing, religious, and

ritualistic beliefs. (Frese)

It is often considered that many factors play a role in the development of pica, however

the exact etiology is unknown. When looking at the consumption of nonnutritive items as a

disorder rather than a tradition, various populations affected would include: those with autism,

developmental disabilities, pregnant women, children, those from under developed countries,

those with a family history of pica, women from countries outside of the US, women of African

American decent, and those with lower socioeconomic status. Although pica does not appear to

have a strict gender preference, it is most commonly seen with children ages 2-6 years, dialysis
patients, and pregnant women. Studies are being done that suggest culture, nutrition, or mental

health may be predisposing factors that play a role in the development of pica. This encourages

the belief that it may be due to both a genetic inclination or acquired in nature. It has been

suggested that a deficiency in iron or zinc may be linked to the consumption of clay and soil, as

soil is high in these two micronutrients. The consumption of dirt is actually the most common

substance eaten with pica. Followed by starch, ice, paint chips, wood/paper, glue, and hair. It is

also believed that ice is consumed when the body is low in iron; whereas some of the other

commonly consumed products may be linked to texture, taste, or smell. (Frese)

Recent evidence suggests that pica may be a type of obsessive-compulsive disorder.

Patients with OCD stated that the consumption of various non-food products was a part of their

daily ritual that they could not stop. Anxiety of these patients is often decreased when their

rituals are carried out. For these types of patients, various obsessive-compulsive medications

have proven to be helpful. Often, the first type of medication prescribed for OCD is an anti-

depressant. (Frese) Common anti-depressants include: Clomipramine, Fluoxetine, or Paroxetine.

Clomipramine has several concerns for dental treatment, these include: the use of local anesthetic

with a vasoconstrictor may need to be reduced, xerostomia, and other changes in salivation that

may increase the risk of caries. Fluoxetine has several concerns for dental treatment, these

include: caution with local anesthetic, xerostomia, taste perversion, SSRI induced bruxism, and

possible increased risk of bleeding. Finally, concerns with paroxetine include: xerostomia,

postural hypotension, abnormal taste, SSRI induced bruxism, and increased risk of bleeding or

prolonged bleeding time. Anti-depressive medications that are used for patients with pica to

assist in treatment of their OCD tendencies may have several negative bodily effects. These
could include: insomnia, headache, anxiety, decreased libido, nausea, diarrhea, weakness,

tremors, chest pain, hypertension, dizziness, and more. (Wynn)

The body may be negatively affected by some of these products or it may not be affected

at all. With soil consumption there is an increase risk of hypokalemia, bowel obstruction,

nutrition deprivation, parasitic infection, or dental injury. Children, immune compromised

individuals, and pregnant women are at an increased risk of developing an infection. Another

issue that may occur would be neurological damage due to the consumption of paint products

containing lead. (Frese)

The oral cavity can be affected by pica in a variety of ways. The consumption of items,

such as soil, causes both abrasion and erosion of the enamel. This also causes damage to current

restorations. Soft tissue damage may also be seen in patients that consume abrasive products.

With nutritional deficiencies, such as the lack of iron and zinc, both systemic and oral signs may

arise. The consumption of soil may also introduce different bacteria into the oral cavity. Some

individuals with pica consume large amounts of starch, which could cause an increase in dental

decay. Other individuals consume the butts of cigarettes after they smoke, this could affect the

health of the periodontal tissues. Alignment and malformation could also play a role, but are not

as likely to occur as abrasion, erosion, decay, or decreased periodontal health. (Barker)

Treatment for those with pica varies greatly as there is not one single cause of the

disorder. The first issue addressed would be medical issues such as bowel obstruction or

poisoning. Nutritional counseling along with education may be the first approach, followed by

behavioral counseling with the identification of the stressors. With children that may have a

mental disability it is important to closely monitor the child as pica most often occurs when the

child is alone. Also, it is helpful to remove the products if possible. When pica occurs in
childhood it often resolves on its own as the child gets older. With pregnant women, the cravings

often clear up after childbirth. Adults with pica may go through phases of remission and return to

the habit if stressors occur. For these patients, identification and stress reduction protocol is often

helpful. (Cole)

The primary concerns for patients with pica when in the dental office are to first be

informed of the disorder and second to not leave the patient unattended. Being that the primary

patients affected by pica are children and those with developmental concerns, the parent is

usually the advocate. When the health care professional is aware of the disorder they can help the

parent look out for signs that the actions are continuing. It is important for the dental professional

to look into unusual patterns of wear. Different treatment methods may be required. The need of

a caretaker is often case-by-case. One may be required for a patient that has pica secondary to a

developmental disorder. However, many patients are okay with being monitored by the health

care professional. Depending on the damage that has been done to the teeth, prescription fluoride

toothpastes may be helpful for sensitivity due to wear. Also, the dental professional should be

careful with any oral sores due to the patient’s pica. Extra attention, topical, or anesthesia may be

helpful to keep the patient comfortable. An extra soft toothbrush may be helpful, along with

reinforced brushing instructions. Those with developmental disabilities may also need additional

toothbrush modifications. For a patient with obsessive-compulsive disorder, a floss aide could be

helpful in channeling the patient’s OCD tendencies into something more productive rather than

consumption of non-food products. Many of these patients have some type of connection to a

mental disability that may require additional time to work with the patient and help where we

can. (Frese) Counseling by a dental professional in the areas of dental health, nutrition, and

dental care would likely be helpful for those that do not realize their pica could be damaging
their health. Dental professionals are often the first responders to patients that do not see a doctor

more regularly. So, as stated previously, it is important for the dental professional to look further

into unusual patterns of wear. Often times we also develop a relationship with the patient in

which they would feel more comfortable sharing their struggles with us than a stranger. (Barker)

In summary, pica is a unique disorder in that there is not one single cause, sign, symptom,

or treatment alone. Pica is most often seen in children, pregnant women, and those with

developmental disorders. It can have minimal effect on the body and oral cavity, or it may cause

more significant damage. At times pica is secondary to something else going on in the body,

such as OCD or nutritional deficiency. Just as there is not one cause of pica, there is not one

treatment alone. Treatment methods may include: medications, nutritional counseling, behavioral

counseling, monitoring, and environmental changes. It is important for a dental professional to

be “ready for anything” when it comes to treating patients.

Work Cited

Frese, P. (2015). Pica. Retrieved from https://www.dentalcare.com/en-us/professional-

education/ce-courses/ce465/toc

Barker, D. (2005). Tooth wear as a result of pica. British Dental Journal. 199, 271-273.

Retrieved from http://www.nature.com/bdj/journal/v199/n5/full/4812651a.html

Cole, L. (2017). The pica-autism connection: help and perspective. Retrieved from

https://www.autismspeaks.org/blog/2013/06/21/pica-autism-connection-help-perspective-

got-questions

Wynn, R. L., Meiller, T. F., & Crossley H. L. (2016). Drug information handbook for dentistry

22nd edition. Hudson, Ohio: Lexicomp, Inc.