From Volume 50, Issue 3, March 2023 | Pages 211-214
Pica is an eating disorder characterized by compulsive eating of non-food items. It can present to dentists through patient medical histories, and also through causing atypical patterns of non-carious tooth surface loss. In highlighting two cases of pica presenting in general practice, we aim to raise awareness of this condition and its dental implications.
Pica is an eating disorder defined as the chewing and/or ingestion of non-nutritious items. The name ‘pica’ originates from the Latin name for magpie, comparing the condition to a magpie's omnivorous eating habits. People living with pica are reported to consume a variety of non-food substances including clay, soil, stones, faeces, lead, plastic, paper, coal, chalk, wood, plaster and cigarette butts.8
Eating non-food substances is common in young children as part of their development. However, pica is defined as persistent eating of non-food substances for a period of over 1 month in someone aged over 24 months.2 Pica can be a learned condition found in 10–15% of people with learning disabilities, such as autism spectrum disorder (ASD).5 Pica is seen in up to 20% of pregnant women and is also found in patients with nutritional deficiencies, particularly iron deficiency.10
Medical complications of pica are dependent on the type and quantity of the ingested substance. Ingestion of hazardous substances can cause toxicity; soil in particular has been reported to lead to parasitic infections, such as toxoplasmosis and toxocariasis.8 Gastrointestinal issues such as obstruction, perforation, ulceration and constipation can occur, in addition to malnutrition and nutritional deficiencies.12
With regard to treatment, this can range from nutritional, psychological, pharmacological, or behavioural management. Nutritional deficiencies are managed through supplementation. Patients with developmental disorders may respond to counselling or psychotherapy to address underlying emotional or psychological problems, or may be helped by cognitive behavioural therapy. Depression, anxiety and certain personality disorders can be managed pharmacologically. Prevention and education about pica are vital for susceptible patients and their families.12
In April 2021, a 48-year-old woman presented in general practice concerned with the appearance and function of her teeth. She was in no discomfort or pain and had not attended a dental practice for many years due to dental anxiety.
She explained she had pica and had chewed and eaten cement and sandstone from a wall near her house for the last 17 years. This had started during pregnancy and persisted afterwards without the knowledge of her friends and family. She explained that her pica was currently in remission as she had attended therapy organized by her general medical practitioner (GP). At the time of presentation, she had not consumed any cement for 1 year.
Medically, she had type II diabetes with hypertension, hypothyroidism and arthritis. She had no allergies and took thyroxine, sertraline, mirtazipine, gliclazide, ramipril, metformin and atorvastatin. She had smoked 20 cigarettes per day for 30 years, and 5 years previously, she had had a period of high alcohol intake of over 50 units per week.
On examination there were no extra- or intra-oral soft tissue findings. There was significant evidence of extensive multifactorial non-carious tooth surface loss (NCTSL) with elements of likely erosive, attritional and abrasive wear (Figure 1). Tooth wear was seen into the pulp of multiple teeth and she had three retained roots.
Oral hygiene was good and the patient explained that she was brushing up to five times daily due to her concern about the appearance of her teeth.
A DPT was taken alongside peri-apical images of upper and lower central incisors (Figure 2) and study models. The patient was prescribed 5000ppm sodium fluoride toothpaste and referred to the restorative dental department of Newcastle Dental Hospital.
The following diagnoses were made:
A treatment plan was put in place to stabilize and restore her dentition in a specialist setting.
An 8-year-old girl attended a routine appointment in general practice with her father in April 2021. Owing to the outbreak of COVID-19 and the reduced provision of routine treatment, it had been over 12 months since the patient's previous recall appointment, and her father was concerned that a recently diagnosed eating disorder had potential to affect his daughter's teeth. She was in no pain or discomfort on presentation, but also had a digit-sucking habit.
The patient had recently been diagnosed with pica through an assessment by her GP. Her father explained she chewed and then swallowed stones, soil and a range of other non-food items. She was undergoing investigation for ASD, but had no other relevant medical history and took no medications.
On examination, the patient had no significant extra-oral findings and no abnormal soft tissue findings. Dentally, she had a substantial anterior open bite and NCTSL seen on the occlusal surfaces of her upper second primary molars. Attritive and abrasive wear was seen into enamel, with flattening of cusp height. No caries was seen on any teeth although oral hygiene was suboptimal.
Figure 3 shows clinical photographs taken from a subsequent appointment after two preformed metal crowns were placed on URE and ULE using the Hall technique. This provided protection for the enamel of these teeth against further NCTSL until their exfoliation. Oral hygiene instruction had been given, but was to be repeated and reviewed at future appointments. Two small traumatic ulcers were also seen at this appointment (seen on palatal midline and at the muco-gingival junction adjacent to URD).
Pica frequently has dental implications. Depending on what substance is ingested and for how long; dental manifestations can range from dental trauma such as oral lacerations, gingival recession, temporomandibular disorder (TMD) and non-carious tooth surface loss. Abrasion and erosion can occur, in addition to staining of teeth and mucosa. Chewing of sharp and rough objects may lead to repeated traumatic ulceration. Poor oral hygiene can progress to gingivitis and then ultimately periodontal disease. Halitosis is also common.6
Tooth surface loss in children has been shown to be continuing to increase since it was first measured in the Child Dental Health Survey of 1993.13 While NCTSL is considered multi-factorial, the most significant factor in this is in children considered to be erosion.9 Should tooth wear patterns in children not fit a characteristic erosive presentation, it would be worth considering pica as a differential cause and gaining further dietary and behavioural information from both the patient and their parent/carer/guardian.
The wear pattern seen in pica can be unusual and not necessarily characteristic of attrition, abrasion and erosion; again, this is dependent on what is ingested. Chewing abrasive substances can result in cupping and grooving of dentine with sharp enamel edges. The wear facets may not match the inter-cuspal position, as seen in attritive wear.3
General dentists should have an awareness of presentations of pica to ensure that any patients that present to them with this condition are appropriately managed. Early detection of pica is essential to maximize the prognosis of any dental intervention.7 Particularly, dentists should be vigilant for oral presentations in susceptible patients such as pregnant women or people with ASD. Dentists should also be aware that people with pica can feel embarrassed by this, so sensitive and considered communication skills are required.5
As dentists, it is important to maintain patient safety. Previous cases have provided examples of pica patients who have had deficiencies of iron and zinc, as well as the risk of ingestion of toxic substances such as lead (used widely in paint in the UK until the 1960s).1,11,13 For these reasons we strongly advise referral of any patients suspected of having pica, but have no existing diagnosis, to their GP.
In general practice, as with all NCTSL, prevention is key in patients with pica. Good oral hygiene practices with high fluoride toothpaste should be encouraged. In close association with the medical team, diet advice to avoid a high acidic or sugary diet should be given. TMD management may be indicated such as the provision of occlusal splints, exercises and analgesics. These preventive measures will help stabilize the wear.4
Pica cases such as these highlight the importance of taking a detailed history with regard to NCTSL. Pica should be considered in unusual or extensive patterns of wear. In cases where the wear is severe and dento-alveolar compensation has occurred, there may be limited space for restoration. There may also be minimal sound enamel to bond to. Referral to tertiary care can be considered for opinions on treatment planning or completion of treatment itself to ensure the best possible dental prognosis. Ultimately, the prognosis of restorative intervention is dependent on whether the individual's pica has stabilized and if the potential for dentally destructive habits has gone.7
Pica is a condition that can present in both adults and children to a dentist in primary care. The dental impact of it may be managed locally or through referral for specialist input. Liaison with medical professionals is often indicated for holistic patient care. Through awareness of this condition and how it may manifest dentally, practitioners can be prepared to best support patients living with or in remission from pica.
