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Effect of pica on dental surfaces
HANDS ON Behavior Effect of pica on dental surfaces Background.—Patients with pica persistently eat or mouth nonnutritive substances, such as clay, soil, sand, stones, grass, hair, feces, lead, and laundry starch. Worldwide, 25% to 33% of small children, 20% of pregnant women, and 10% to 15% of individuals with learning disabilities exhibit this eating disorder. In some tribal-based societies, pica is considered a culturally sanctioned practice. However, serious medical outcomes can occur, depending on what and how much is ingested. These include lead and mercury poisoning, hyperkalemia, parasitic infections, and various gastrointestinal tract problems. The reason for the disorder has been assigned to various nutritional deficiencies, but no links are clearly causative. Patients often have iron-deficiency anemia, which has been considered a part of the syndrome by some. Pica manifested in 1 patient as generalized tooth surface loss and damaged restorations. Case Report.—Woman, 56, was referred to the restorative dentistry department for an evaluation of tooth wear. No parafunctional habits were reported to the referring dentist, but further questioning led the patient to admit she mouthed and ground stones and grit between her teeth. She began this habit during her first pregnancy, but discontinued it after the pregnancy and did not take it up again with her second pregnancy. However, she began again during her third pregnancy and continued the practice for 10 to 14 years, stopped, and restarted for 5 years before she was referred. She expressed no difficulty deciding to stop and maintaining that decision but could not tell why she started in the first place or continued at the indicated intervals.
138 Dental Abstracts
Near the time of her most recent reestablishment of the habit, she was diagnosed with iron-deficiency anemia. She also reported significant stress in her life at that point. She was taking iron supplements and hormone replacement therapy, but did not smoke. Oral examination found that her tongue was slightly atrophic and depapillated. She maintained a reasonable oral hygiene level and had good periodontal health with no evidence of bleeding or significant pockets. The tooth surface loss was widespread and attributable to abrasive forces (Fig 1). The teeth showed grade 4 wear, based on the Smith and Knight Toothwear Index. The patient also had fractured and roughened porcelain crowns, with the anterior teeth opposing the crowns showing extreme wear. A significant space anteriorly resulted from the retruded contact position between teeth 28 and 36. Bone loss was minimal, and no caries or periapical pathology was found on radiographic examination. Blood tests for various deficiencies yielded normal values except for slightly low levels of serum ferritin. Management included a combination of fixed and removal prosthodontics. Porcelain-fused-to-metal crowns were used for the upper arch, with tooth 23 serving as an abutment tooth for a cantilever bridge to replace tooth 24. Teeth 16 and 28 received gold onlays. The upper cast was evaluated before placement with the intention of designing a partial denture. The restorations on teeth 16, 14, 23, 24 (pontic), and 28 were milled to incorporate rests, undercuts, and guide planes as appropriate. The partial denture
Fig 1.—Preop photographs showing the widespread tooth surface loss and fractured restorations discussed in the text. Anterior views with teeth together (A) and apart (B) and upper (C) and lower (D) occlusal views. (Courtesy of Barker D:Tooth wear as a result of pica. Br Dent J 199:271-273, 2005. Reprinted by Nature Publishing.)
for the upper arch was composed of cobalt and chrome. A porcelain-fused-to-metal crown was used in the lower arch for tooth 44. Teeth 43, 32, 41, 31, 32, 33, and 34 received indirect composite onlays. Discussion.—Pica is uncommon in adults who do not have learning disabilities and who are not pregnant. This patient was reluctant to disclose her pica and began the behavior originally during pregnancy. In addition, she had a history of anemia, which is often found in persons with pica. Once her habit was exposed, appropriate treatment was undertaken. In cases of unusual patterns of wear, pica should be considered.
Clinical Significance.—Habits destructive to oral tissues can be difficult to diagnose. In this report of pica, persistent eating or mouthing of nonnutritive materials was determined—only after a detailed interview— to be the cause of the tooth wear.
Barker D: Tooth wear as a result of pica. Br Dent J 199:271-273, 2005 Reprints available from D Barker, The Dental Hosp, Newcastle-uponTyne, NE7 7GA; e-mail: [email protected]
Volume 51 • Issue 3 • 2006 139
138 Dental Abstracts
Near the time of her most recent reestablishment of the habit, she was diagnosed with iron-deficiency anemia. She also reported significant stress in her life at that point. She was taking iron supplements and hormone replacement therapy, but did not smoke. Oral examination found that her tongue was slightly atrophic and depapillated. She maintained a reasonable oral hygiene level and had good periodontal health with no evidence of bleeding or significant pockets. The tooth surface loss was widespread and attributable to abrasive forces (Fig 1). The teeth showed grade 4 wear, based on the Smith and Knight Toothwear Index. The patient also had fractured and roughened porcelain crowns, with the anterior teeth opposing the crowns showing extreme wear. A significant space anteriorly resulted from the retruded contact position between teeth 28 and 36. Bone loss was minimal, and no caries or periapical pathology was found on radiographic examination. Blood tests for various deficiencies yielded normal values except for slightly low levels of serum ferritin. Management included a combination of fixed and removal prosthodontics. Porcelain-fused-to-metal crowns were used for the upper arch, with tooth 23 serving as an abutment tooth for a cantilever bridge to replace tooth 24. Teeth 16 and 28 received gold onlays. The upper cast was evaluated before placement with the intention of designing a partial denture. The restorations on teeth 16, 14, 23, 24 (pontic), and 28 were milled to incorporate rests, undercuts, and guide planes as appropriate. The partial denture
Fig 1.—Preop photographs showing the widespread tooth surface loss and fractured restorations discussed in the text. Anterior views with teeth together (A) and apart (B) and upper (C) and lower (D) occlusal views. (Courtesy of Barker D:Tooth wear as a result of pica. Br Dent J 199:271-273, 2005. Reprinted by Nature Publishing.)
for the upper arch was composed of cobalt and chrome. A porcelain-fused-to-metal crown was used in the lower arch for tooth 44. Teeth 43, 32, 41, 31, 32, 33, and 34 received indirect composite onlays. Discussion.—Pica is uncommon in adults who do not have learning disabilities and who are not pregnant. This patient was reluctant to disclose her pica and began the behavior originally during pregnancy. In addition, she had a history of anemia, which is often found in persons with pica. Once her habit was exposed, appropriate treatment was undertaken. In cases of unusual patterns of wear, pica should be considered.
Clinical Significance.—Habits destructive to oral tissues can be difficult to diagnose. In this report of pica, persistent eating or mouthing of nonnutritive materials was determined—only after a detailed interview— to be the cause of the tooth wear.
Barker D: Tooth wear as a result of pica. Br Dent J 199:271-273, 2005 Reprints available from D Barker, The Dental Hosp, Newcastle-uponTyne, NE7 7GA; e-mail: [email protected]
Volume 51 • Issue 3 • 2006 139