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Pica
Patricia Frese, RDH, MEd
Continuing Education Units: 1 hour
Online Course: www.dentalcare.com/en-US/dental-education/continuing-education/ce465/ce465.aspx
Disclaimer: Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or
procedures into their practice. Only sound evidence-based dentistry should be used in patient therapy.
The goal of this course is to provide the dental team with the skills and knowledge to recognize the
symptoms of pica and appropriately manage the dental needs of patients who exhibit pica.
Conflict of Interest Disclosure Statement
• Ms. Frese has done consulting work for P&G.
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Crest® Oral-B® at dentalcare.com Continuing Education Course, November 2, 2015
Approved PACE Program Provider
The Procter & Gamble Company is designated as an Approved PACE Program Provider
by the Academy of General Dentistry. The formal continuing education programs of this
program provider are accepted by AGD for Fellowship, Mastership, and Membership
Maintenance Credit. Approval does not imply acceptance by a state or provincial board
of dentistry or AGD endorsement. The current term of approval extends from 8/1/2013 to
7/31/2017. Provider ID# 211886
Overview
This course is an introduction to the eating disorder pica. This eating disorder has been recognized for
centuries and is still an occasional problem today. The course will explore the history, prevalence and
etiology of pica. The various pica substances consumed, diagnosis, and complications will also be covered.
Management techniques for the dental team and treatment options for patients with pica will be presented.
Learning Objectives
Upon completion of this course, the dental professional should be able to:
• Define pica.
• List three possible causes of pica.
• Recognize intraoral signs of pica.
• Describe how to educate patients on the dental health risks of pica.
• Describe appropriate dental management techniques for patients with pica.
• Describe appropriate medical and dental treatment options for patients with pica.
• Identify additional resources for patients and dental professionals.
Course Contents
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Introduction
Brief History
Prevalence
Etiology and Conditions Associated with Pica
Substances Consumed
Diagnosis
Complications
Dental Concerns and Management
Treatment
Conclusion
Course Test
References
About the Author
Pica is the most common eating disorder in
individuals with developmental disabilities.6 In
some societies, pica is a culturally sanctioned
practice and is not considered pathologic. The
consequences of pica can be benign or lifethreatening.6
Introduction
Pica is included in a broad category of eating
disorders. Pica is defined as a pattern of consuming
nonfood materials, such as soil, clay and hair, for
a period of at least one month. This ingestion of
materials is inappropriate to the developmental level
of the individual. Therefore, it does not include the
exploration or accidental ingestion of nonnutritive
substances by children under the age of 2.
Occasionally, the definition is broadened to include
the mouthing of nonnutritive substances.6
According to The Diagnostic and Statistical
Manual of Mental Disorders: Fifth Edition (DSM-5),5
to be diagnosed with pica a person must display:
• Persistent eating of nonnutritive substances
for a period of at least one month.
• The eating of nonnutritive substances is
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inappropriate to the developmental level of the
individual.
• The eating behavior is not part of a culturally
supported or socially normative practice.
• If occurring in the presence of another mental
disorder (e.g., autistic spectrum disorder) or
during a medical condition (e.g., pregnancy),
it is severe enough to warrant independent
clinical attention.
of “normal foodstuffs” has cultural implications.16
In addition, those who practice pica may be
hesitant to divulge such a practice. All these
factors combine to make precise statistics on the
prevalence of pica very challenging.
Pica has been practiced by a wide variety of
populations4,11,13,15 including:
• Individuals with autism and other
developmental disabilities
• Pregnant women
•Children
• Individuals from developing countries
• Women born outside the United States
• African-American women
• Individuals of lower socioeconomic status
• Those with a family history of pica
Note: Pica often occurs with other mental health
disorders associated with impaired functioning.
Brief History
The term pica comes from the Latin word for
magpie. Magpies show a propensity to eat almost
anything, including nonfood items.13 The Eurasian
Magpie is Pica pica.
It is estimated that pica affects:4
• 10-30% of children 1-6 years old
• 20% of dialysis patients
• 20% of pregnant women
Pica has been known throughout the ages, dating
back to 1800 BC in Sumeria, Egypt and China.14
Clay eating for medicinal purposes dates back to
10 BC.10 The eating of dirt and clay was known
to the Greeks and Romans and was recorded in a
13th century Latin work.13 The first medical text
reference to pica occurred in 1563 with an entry on
geophagia (eating earth or soil-like substrates such
as clay or chalk) in pregnant women and children.12
Etiology and Conditions Associated with Pica
The exact etiology of pica remains unknown despite
the fact that pica has been reported since antiquity.
Pica is considered a multifactorial phenomenon
because of this potential for multiple etiologies.1,4
Several theoretical approaches attempt to explain
pica from nutritional, sensory, neuropsychiatric,
ethnic, or psychosocial perspectives.4,6,13
Pica still occurs in some modern cultures as a
ritualistic practice. Geophagia was a common
practice in the southern Unites States during the
1800s. It has been practiced as part of religious
ceremonies, magical beliefs and attempts at
healing.12 During the 1950s and 1960s, geophagia
was so common in the south that one could
purchase small bags of clay at bus stops. In
addition, as northern migration occurred, bags of
special local clay were mailed by southern family
members to northern relatives who still craved the
clay.13 Currently, white clay can be purchased in
southern grocery stores as well as online.2
The most common nutritional theories attribute
pica to deficiencies of specific minerals including
iron and zinc. Several case studies describe
patients with low iron or zinc levels whose
pica behavior diminishes with iron or zinc
supplementation.4 Clay, especially red clay from
the southern United States, is high in iron and may
prompt pica behavior in an attempt to supplement
Prevalence
Pica has been described in the literature as
“underreported” and “unrecognized.”6 There have
been few epidemiologic studies detailing the
prevalence of pica.13 There is disagreement as to
the precise definition of pica. For instance, the use
of the terms nonnutritive and normal foodstuffs
have limitations. Cornstarch provides calories and
soils may provide micronutrients. The definition
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for this micronutrient.16 However, clay eating may
be the cause of iron deficiency anemia, as clay
is an iron chelator and binds iron, reducing its
bioavailability. A less common theory postulates
that people eat nonfood substances because they
do not have anything else to eat.16
are used to treat nausea, diarrhea and vomiting.16
Clay is also consumed to coat the stomach and
intestines before eating foods such as fish that
may contain toxins or pathogens.4,16 This coating
could slow the absorption of these toxins and
pathogens.16 It is understandable that children
could mimic the pica behavior of those around
them as a practice as well as a method of relieving
intestinal distress.4
Sensory theories focus on the reports that
patients say they enjoy the taste, texture or smell
of the item they are consuming.13 The “crunch”
of cornstarch or clay, the “chew” of rubber bands
or the smell of foam rubber are described as
pleasing to the consumer.
Psychosocial theories of the etiology of pica
suggest an association with family stress (abuse,
parental separation, neglect or poor parenting), a
smaller social support network and as a display
of aggression.4,13
A neuropsychiatric component is supported by
evidence in laboratory animals with certain brain
lesions and abnormal eating behaviors in these
animals. Therefore, pica may be associated
with certain brain disorders in humans.13 Recent
evidence indicates that pica may be part of the
obsessive-compulsive disorder (OCD) spectrum
of diseases. There are case reports from five
patients undergoing OCD treatment who indicate
their pica behavior is a ritualistic behavior they
are compelled to carry out and that eating the
substance lessens the anxiety or tension they
experienced.13 Traditional OCD therapy, which is
primarily psychotherapy, had a variable effect on
the pica behavior in these patients. These case
reports lend support to the theory that, at least
in some patients, pica may be a manifestation
of OCD.13 Pica has comorbid associations with
other diseases and disorders including autism,
autism spectrum disorders (ASD), psychosis, and
developmental disabilities.2,7,11,13 Neurochemical
and neuropathological changes that occur in
patients with dementia may also contribute to a
change in eating habits resulting in pica behavior.4
Substances Consumed
Substances may be labeled or identified as
objects of pica. Certain groups may show a
preference for a substance as part of their pica
behavior. It is interesting to note that the range of
items reported has changed little over 4 centuries.
Table 1 presents a selection of information on the
more common items consumed.1,2,6,10,13,16
Diagnosis
There are no definitive laboratory tests to provide
a diagnosis of pica. Instead pica is a clinical
diagnosis, confirmed by the patient’s history.11
Suspicions about the presence of pica behavior
should be investigated. Health care providers
should ask the patient (or parent or caregiver,
as appropriate) about pica behavior or unusual
cravings, especially in high risk groups. Some
patients may self-report the pica behavior.
However, patients are likely to underreport because
of embarrassment or because they are not aware
the behavior could be problematic.13 An evaluation
of symptoms may be the best approach. If a
patient has anemia, lead poisoning or intestinal
obstruction, the health care provider should
investigate pica as a cause. Certain laboratory
tests can be performed to confirm the symptoms,
but the cause of the pica behavior must be
admitted by the patient. Parents may be counseled
to observe children for signs of pica behavior.
Pica is a widespread practice in India and has been
reported in Australia, Canada, Israel, Iran, Uganda,
Wales and Jamaica.6 Pica is culturally acceptable
among families of African heritage and is reported
to be problematic in 70% of provinces in Turkey.
In Guatemala, clay is molded into small religious
icons, called panito del senor, and consumed. Pica
has been associated with fertility rites; the eating
of soil is thought to ensure future offspring. Clay
and starch have been eaten by pregnant women
to ease morning sickness.4 Some clay contains
kaolin, formerly the active ingredient in Maalox®
and Kaopectate. These over-the-counter products
Complications
Complications of pica are generally classified
into five groups.4,13 First is inherent toxicity
where there are direct toxic effects from the
consumption of lead, mercury, arsenic or other
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Table 1. Common Items Consumed.
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is a symptom of anemia, and the patient should be
questioned about ice or freezer frost consumption.
Ingestion of cigarette butts poses multiple risks,
such as gingival recession, periodontal disease and
oral cancer.4,6 Pica behavior occasionally manifests
as overconsumption of food items. If lemons
or candy are consumed in this manner, enamel
erosion and tooth decay can result. In addition,
caution is necessary if the patient or health care
provider substitutes sugar containing foods for the
pica substance.
All dental patients should have a thorough
medical history taken and reviewed. A complete
oral exam should be performed. Any unusual
findings should be investigated. Patients with
autism, pregnant women, and children with
developmental disorders are at higher risk for
pica. Any suspicions should be investigated
further and patients (or their parents or
caregivers, as appropriate) should be directly
questioned about pica behavior. If nutritional
deficiencies are suspected, a consultation with
the patient’s physician is warranted.1,4
heavy metals. An example is eating paint chips
from lead paint or soil surrounding a house
painted with lead-based paint. In a child, this can
cause irreversible neurological damage. In an
adult, it can cause behavior changes. Another
example is consumption of clay which could lead
to hypokalemia. Potassium is a critical electrolyte,
necessary for proper nerve and muscle cell
function, especially in the heart. Second is the risk
of obstruction or aspiration. Bezoars, indigestible
masses that lodge in the digestive tract, may form.
A trichobezoar forms as a result of hair eating.
Consumption of other objects, such as metal,
can block the trachea, esophagus or intestines.
Subsequent perforation, peritonitis and death can
result. Third is excessive caloric intake, typically
seen in amylophagia (starch eating). Fourth is
general nutritional deprivation. Nonnutritive items
like dirt, gravel, wood or ice are eaten in place
of a variety of nutritive foods. Young children
may exhibit a failure to thrive and adults may
appear anorexic. Fifth is other complications
such as parasitic infections or dental injury.
If contaminated feces or dirt are consumed,
toxoplasmosis (infection from a parasite found
in cat feces) or toxocariasis (infection from a
roundworm found in dog and cat feces) may
result. While healthy adults may not develop
symptoms, children, immunocompromised
individuals and pregnant women are at greater risk
for developing a severe infection.13
Treatment
Treatment of pica should take multiple approaches
as no one treatment is universally effective. The
first concern would be the treatment of medical
problems such as obstruction, infection or heavy
metal poisoning.13,15 Nutritional counseling might
be the first wave of intervention.13 Education about
proper nutrition and elimination of consumption
of nonfood items as well as iron or zinc
supplementation may be effective. Patients can
be encouraged to substitute better food choices
for the craved substance: sugar-free candies for
pebbles, powered milk for starch or sugar-free
ice pops for ice or freezer frost. Psychological
approaches could include counseling and
behavior therapy. Interventions such as positive
reinforcement for eating from a plate have
been effective in children with developmental
disabilities. Mild aversion therapy, where
unpleasant consequences or punishment followed
by positive reinforcement for eating the correct
foods, has been successful.13 A combination of
positive reinforcement and response reduction,
blocking or obstructing the patient’s attempt
to consume the pica substance, have shown
good efficacy.11 The identification of stressors
followed by stress reduction therapy is warranted,
Dental Concerns and Management
The mouthing or chewing of pebbles or grit can
cause wear to both the natural dentition and
restorations. Chewing of hard objects like metal or
ice can cause tooth or restoration fracture. Sharp
objects like glass or wood splinters can cause
lacerations or other trauma. Atrophy of the tongue
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especially in children where family-based stress
may play a role.13 In certain cases, pharmacological
intervention may be necessary. Selective serotonin
reuptake inhibitors, prescribed for patients with
anxiety, depression or other mental disorders;
atypical neuroleptics (olanzapine) and attentiondeficit/hyperactivity disorder medications
(methylphenidate) have been used, with varying
levels of success.8,11,13,15 Not all pica substances are
dangerous and intervention might not be necessary
in some cases.13 For instance, if the pica substance
being consumed is small quantities of cornstarch
and no medical or dental issues are present, there
may be no benefit to counselling the patient to stop
consuming the cornstarch. The patient should be
educated about consuming excessive amounts of
cornstarch due to additional empty calories.
in childhood and the patient enters teen or adult
age.13,15 Prevention strategies may be important
as well. Pica is most often practiced when the
patient is alone or unsupervised.8 Increased
supervision, especially in children and patients
with developmental disabilities, can prevent or
lessen the behavior. Knowing about and getting
proper nutrition may be helpful.15 Removing
or reducing access to the source of the pica
substance (removing lead-based paint chips
or monitoring children playing in sand boxes)
is important.13 Stool checks may be used with
institutionalized patients.8
Conclusion
Having the knowledge and skills to recognize the
oral implications of pica, educate the patient or
patient’s family about the concerns and provide
appropriate referral is important to provide quality
care to dental patients.
Pica can last for a number of years then resolve
on its own; especially when the behavior is seen
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Course Test Preview
To receive Continuing Education credit for this course, you must complete the online test. Please go to:
www.dentalcare.com/en-US/dental-education/continuing-education/ce465/ce465-test.aspx
1.
Pica is defined as the consumption of nonfood materials for a period of at least one year.
a.True
b.False
2.
Pica can be diagnosed in children as young as 18 months.
a.True
b.False
3.
Some definitions of pica include mouthing of objects.
a.True
b.False
4.
Pica is the most common eating disorder in individuals with developmental disorders.
a.True
b.False
5.
Pica is not considered pathologic as it is a culturally sanctioned practice in some countries.
a.True
b.False
6.
Consequences of pica behavior can be both benign or life-threatening.
a.True
b.False
7.
Pica can affect:
a.Children
b. Pregnant women
c. Patients on dialysis
d. All of the above
8.
Pica may be caused by:
a. Iron deficiency
b. Cultural practices
c. Psychosocial issues
d. All of the above
9.
Geophagia is the most common type of pica.
a.True
b.False
10. Amylophagia is the second most common type of pica.
a.True
b.False
11. There is an association with patients who consume glue and patients who have sickle cell disease.
a.True
b.False
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12. Complications of pica can include:
a.Malnutrition
b. Intestinal distress
c.Obstruction/aspiration
d. All of the above
13. Intraoral signs of pica can include:
a. Tooth wear
b.Erosion
c. Oral cancer
d. All of the above
14. If pregnant women show intraoral signs of pica, the dental health care professional should directly
question the patient about pica behavior.
a.True
b.False
15. Treatment of pica may include:
a. Behavior therapy
b. Pharmacological intervention
c. Nutritional counseling
d. All of the above
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References
1. Barker D. Tooth wear as a result of pica. Br Dent J. 2005 Sep 10;199(5):271-3.
2. Blinder BJ. An update on pica: prevalence, contributing causes, and treatment. Psychriatric Times.
2008 May;25(6). Accessed October 19, 2015.
3. Chakraborty S, Sanyal D, Bhattacharyya R. A unique case of pica of adult onset with interesting
psychosexual aspects. Indian J Psychol Med. 2011 Jan;33(1):89-91.
4. Cooper MD. Pica. Access. 2010 May-June;24:39. Accessed October 19, 2015.
5. Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, Va: American Psychiatric
Press, 2013.
6. Ellis CR, Schnoes, CJ, Pataki C, et al. Medscape. Practice Essentials. Pica: Practice Essentials.
Updated September 23, 2014. Accessed October 19, 2015.
7. Hergüner S, Ozyildirim I, Tanidir C. Is Pica an eating disorder or an obsessive-compulsive spectrum
disorder? Prog Neuropsychopharmacol Biol Psychiatry. 2008 Dec 12;32(8):2010-1.
8. Khan Y, Tisman G. Pica in iron deficiency: a case series. J Med Case Rep. 2010 Mar 12;4:86.
9. Klein A, Schröder C, Heinemann A, et al. Homicide or suicide? Xylophagia: a possible explanation for
extraordinary autopsy findings. Forensic Sci Med Pathol. 2014 Sep;10(3):437-42.
10. Lacey EP. Broadening the perspective of pica: literature review. Public Health Rep. 1990 Jan-Feb;
105(1):29-35.
11. Mishori R, McHale C. Pica: an age-old eating disorder that’s often missed. J Fam Pract. 2014 Jul;
63(7):E1-4.
12. Parry-Jones B, Parry-Jones WL. Pica: symptom or eating disorder? A historical assessment. Br J
Psychiatry. 1992 Mar;160:341-54.
13. Rose EA, Porcerelli JH, Neale AV. Pica: common but commonly missed. J Am Board Fam Pract. 2000
Sep-Oct;13(5):353-8.
14. Stokes T. The earth-eaters. Nature. 2006 Nov 30;444(7119):543-4.
15. U.S. National Library of Medicine. MedlinePlus. Pica. Updated 2/14. Accessed October 19, 2015.
16. Young SL, Wilson MJ, Miller D, et al. Toward a Comprehensive Approach to the Collection and
Analysis of Pica Substances, with Emphasis on Geophagic Materials. PLoS ONE 2008 3(9):e3147.
Accessed October 19, 2015.
Additional Resources
For Patients and Parents
•KidsHealth
• Psychology Today
• Autism Speaks
• American Pregnancy Association
• eatright PRO
For Dental Professionals
• NIH U.S. National Library of Medicine
• American Dental Hygienists’ Association
• Psychology Today
Selected Case Reports of Pica
• Man swallows 227 metal objects including kitchen forks, coins and a screwdriver.
• In the Glore Psychiatric Museum, St. Joseph, Missouri, there is an arrangement of 1,446 items
swallowed by a patient and removed from her intestines and stomach. She died during surgery from
bleeding caused by 453 nails, 42 screws, safety pins, spoon tops, and salt and pepper shaker tops.
• Case reports of ice cube eating and rubber band chewing.
• Case report of young girl consuming brick pieces.
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About the Author
Patricia Frese, RDH, MEd
Patricia Frese is Professor of Dental Hygiene at the University of Cincinnati Blue
Ash College Cincinnati, Ohio. She has been in education since 1980. She is a 1976
graduate of the dental hygiene program at Raymond Walters College (now UC Blue
Ash). She has private practice experience in general, research and periodontal practice
settings. She has presented on a variety of topics at professional meetings. Pat is an
active member of the American Dental Hygienists’ Association.
Email: [email protected]
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