M. Dean Wakham, DMD, A. Paul Burtner, DMD, Donald R. McNeal, DMD, MPH, Timothy P. Gawey, DMD, Susan Bedinger, PhD
Pica: a peculiar behavior with oral involvement Pica is a behavior commoniy dispiayed by children, pregnant females, and individuals with mental retardation. A population of institutionalized adults with mental retardation was assessed for pica. Of this population, 10.8%were Identifled with this behavior. Also, this article discusses aspects of pica and describes how this behavior can affect the mouth.
ica is an eating disorder that has been noted for centuries. According to Danford', clay lozenges were ingested for medicinal purposes as early as 10 BC. The American Psychiatric Association (DSM-III-R)2defines pica as the ingestion of non-nutritive or inedible substances and requires repeated ingestion of a non-nutritive substance for at least one month before pica is considered as a diagnosis. A review of the literat~rel-~, however, indicates that this definition has been modified. For example, some investigators consider pica the ingestion or mouthing of non-food items only; others identify this behavior with a peculiar craving for a food substance8or bringing an inedible item into contact with the lips4J0. Small children, individuals with mental retardation, and pregnant females most frequently display this behavior? First, pica in children is usually seen between 12-18 months of age and is not considered abnormal. An infant or child may ingest a variety of things, such as dirt, pebbles, string, or insects. Beyond 18 months, however, this behavior may be considered pathological.4 Second, pica is one of the most frequently observed eating disorders in institutionalized mentally retarded individuals. Prevalence figures for non-food pica in the institutionalized mentally retarded range from 9.2%0* to 16.7%."". McAlpine and Singh4 described pica in institutionalized mentally retarded persons and reported that clothes, dirt, dust, or fluff off the floor, toys, paper, grass, and cigarette butts are a few items used as objects of pica. Third, the
prevalence of pica in pregnant women from low socio-economic classes may be as high as 60%.9 Non-food items craved by pregnant women include laundry starch, clay, and refrigerator frost; food items include fruits, vegetables, and sweet or sour foods.'j9 In an investigation of institutionalized mentally retarded adults, Danford and Hube$ found that 25.8% exhibited pica. McAlpine and Singh4 collected data on a population of institutionalized people with mental retardation and found that 9.2%of the group exhibited the behavior. In their study, they did not observe pica in any individual over 44 years of age. However, in another study, pica was observed to occur over a broad age range. Furthermore, in institutionalized populations, pica occurred more frequently in the profoundly mentally retarded?r8 The purpose of this report is to familiarize oral health care professionals with pica and to discuss various aspects of this behavior which may be observed. Also, the results of a survey that identified pica in institutionalized individuals with mental retardation will be reported.
Methods A group of 749 individuals ranging in age from 11years to 81 years (mean age = 39.8), 477 males and 272 females, and living in a state institution for developmentally disabled individuals was evaluated for pica (Table 1). The assessment instrument, developed by three dentists experienced in detecting pica, consisted of a list of items that are commonly ingested by individuals demonstrating this behavior. Findings were
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Table 1. Sex and age of institution's population.
k Sex Male
Table 2. Pica by sex and race.
Table 3. Plca by age and sex.
recorded by indicating either a positive or negative preference for a certain substance. The items that were selected during pica were calculated as a percentage based on a ratio of the number of individuals who selected the item and the total number of individuals with this behavior. The data were obtained from various sources: the medical chart, direct care staff, nurses, psychologists, physicians, and through direct Table 4. Items selected for pica.
Paper cloth or rags
ResuIts Of the 749 individuals surveyed,
wood, sticks, or twigs
observation of individuals in their homes during oral hygiene monitoring sessions. Subjects were observed at random while they were functioning in their normal environment. Occasionally, some subjects were identified exhibiting pica at various locations on the institution's grounds. The criteria used to identify individuals who exhibited pica were similar to those used by McAlpine and Singh4 and by Winton and Singh12. For example, individuals were considered to exhibit pica if they mouthed (sucked or bit an object), pouched (held items in their mouths), swallowed, or placed non-nutritive items to their lips.
10.8% (n = 81) were found to exhibit
pica (Table 2). The group with the most individuals exhibiting pica was in the age range of 22-45 years, which was 7.3% (n = 55) of the institution's population (Table 3). Also, the individuals in this age range constituted the largest portion (74.1%, n = 555) of the institution's population. Individuals that were found with this disorder in the age range of 46-65 years were
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3% (n = 22) of the total population, with the other age groups comprising a small percentage of the group that was surveyed (0.5%, n = 4). The youngest person exhibiting pica was 19 years old and the oldest, 75 years old, whereas the mean age was 39.4 years. Additionally, the majority of individuals with pica were profoundly or severely mentally retarded (90.1%,n = 73), with the remainder being moderately or mildly mentally retarded. Table 4 enumerates the various items selected by the study subjects for pica in declining order. Multiple items were frequently used by the same subject at differing/ same observations. Thus, the totals amount to greater than 100%. Other item categories include pieces of rubber, moss, ink pens, and straw.
Discussion A thorough knowledge of the patient's medical history should assist the clinician in diagnosing pica and preventing complications. In addition to the medical history, the patient evaluation should include questions about dietary habits, blood analyses for lead dete~tion'~, and abdominal radiographs to detect foreign object~'~,'~. For patients with limited communicative abilities, the parents or legal guardians can usually provide valuable information that will facilitate the diagnosis. Once a definitive diagnosis of pica is established, various strategies are available for its prevention and treatment.1-6,9,11,'2,1~19 Behavioral therapy and nutritional supplementation, the most common methods of treating pica, have shown short-term success; however, the long-term effects of these treatments require further study. A dental examination may provide evidence that a person is engaging in pica. For example, upon inspection of the oral cavity, the clinician may find inedible items in the patient's mouth. An odor of tobacco on the breath of a mentally retarded individual who does not use tobacco suggests pica for cigarettes. Tobacco debris or an actual cigarette filter may be discovered in the patient's mouth (Fig. 1).Undiag-
flg 1. Cigarette filter located under patlent's tongue.
Fig 2. A small piece of wood located between teeth.
Fig 3. Ulceratlon on ventral surface of tongue caused by object lodged between patlent's teeth.
nosed lead intoxication in infants or children who have ingested leadbased paint may result in neurological damage and mental retardation.13 Toxemia from lead poisoning can cause a gingival "lead line". Other oral sequelae from lead poisoning are ulcerative stomatitis, excess salivation, metallic taste, and salivary gland enlargement.20 Moreover, examination of the oral tissues can reveal signs of an undiagnosed medical problem that can cause pica to occur. For example, iron deficiency anemia has been reported to be a cause of pica.11J6-18 Oral manifestations of this deficiency include pallor of the gingiva and mucosa. The tongue will exhibit changes on the dorsal and lateral surfaces, with atrophy of the papillae, and the color will vary from pink to red. Accompanying the oral changes will be symptoms of a sore or burning tongue. Angular cheilitis and leukoplakia, also, are commonly seen as signs of iron deficiency anemia.21 Adverse dental sequelae have not been cited frequently as a complication of pica. Abbey and Lombardz reported a case that involved a pregnant female who routinely consumed clay during her seven pregnancies. Her dentition revealed general occlusal abrasion with extreme wear of the maxillary lingual surfaces and the mandibular incisal surfaces. Because there were no controlled studies that cited a direct link between tooth abrasion and clay or dirt consumption, the investigators concluded that there was no direct cause-and-effect relationship from this behavior. It was suggested that if an
association existed between pica and dental abrasion, then continuation of this behavior could lead to serious dental complications. Another possible complication of pica which could affect the oral structures is ingestion of sharp or hard objects. These objects can lodge between teeth, resulting in injury to the periodontium or adjacent soft tissues. In Fig. 2 is shown a mentally retarded person who has a sharp object lodged between the canine and first premolar in the lower right quadrant, causing soft-tissue injury, resulting in an ulceration under the tongue (Fig. 3). The patient came to the dental clinic for a routine dental examination and debridement when this object was discovered and removed from his mouth. A review of this individual's dental record revealed that approximately five years prior, a piece of wood which had caused an ulcer to develop on the ventral surface of the tongue was removed from between his teeth. Coprophagia, the ingestion of feces, can have a detrimental effect on oral hygiene and the oral tissues. Dura et aLZ3reported on coprophagia and discussed the effects of pica in a profoundly mentally retarded female who had chronic lesions in her mouth. A combination of lip biting and ingestion and pouching of feces by this individual resulted in an oral environment unfavorable for healing.
and pregnant females. Numerous investigators have reported their findings on pica and discussed its medical c~n~equence~.~-"~'~~'~'~~~~ The intent of this report was to familiarize the oral health care professional with pica and various aspects of this behavior. Also, the results of our study of institutionalized individuals with mental retardation indicated that 10.8% exhibited pica. Males exhibited this behavior most frequently, and it was found most commonly in individuals from 22 to 45 years old. String and cigarette butts were most frequently selected by individuals engaging in pica. There are only anecdotal data suggesting that chronic pica is detrimental to the oral hard and soft tissues. In this report, we have presented an example in which an individual with mental retardation consumed a hard object which resulted in trauma to the soft tissue under the tongue. Further investigation of substances selected for pica and their effects on oral structures is warranted. As a result of the process of deinstitutionalization, people with mental retardation who were once treated by dentists in an institutional dental practice may now seek treatment from a clinician in private practice. The community oral health care provider who is familiar with the signs and symptoms associated with pica can inform parents, guardians, and other care-givers that this behavior is suspected, educate them as to the possible complications, and provide proper care to prevent future adverse developments.
Summary Pica is a peculiar behavior that occurs ~ o r l d w i d e ' ,and ~ ~ ,is~ com~ monly associated with children, individuals with mental retardation,
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We acknowledge the Community of Tacachale, Department of Health and Rehabilitative Services, in supporting this research. We wish to thank the institution’s direct-care staff and health-care providers. Dr. Wakham was a Clinical Instructor in the Department of Community Dentistry, University of Florida. He is currently a second-year Resident, University of Tennessee, Department of Orthodontics. Dr. Burtner is Associate Professor, Department of Community Dentistry, University of Florida. Dr. McNeal is Professor and Chairman, Department of Community Dentistry, University of Florida. Dr. Garvey is a Clinical Instructor, Department of Community Dentistry, University of Florida. Dr. Bedinger is Senior Psychologist, Community of Tacachale, Department of Health and Rehabilitative Services, Gainesville, Florida. 1. Danford DE. Pica and nutrition. Ann Rev Nutr 2303-22,1982. 2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed. revised. Washington (DC): American Psychiatric Association, 69,1987. 3. Lacey EP. Broadening the perspective of pica: literature review. Pub Health Rep 10529-34,1990. 4. McAlpine C, Singh NH. Pica in institutionalized mentally retarded persons. J Ment Defic Res 30:171-8,1986. 5. Sayetta RB. Pica: an ovenriew. AFP 33:181-5,1986.
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