Oral piercing: A risky fashion

RC Pramod; KV Suresh; Vidya Kadashetti; KM Shivakumar; Pramod S Ingaleshwar; Sharan J Shetty

doi:10.4103/0974-7761.121257

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REVIEW ARTICLE

Year : 2012 | Volume : 2 | Issue : 2 | Page : 56-60

Oral piercing: A risky fashion

RC Pramod¹, KV Suresh², Vidya Kadashetti¹, KM Shivakumar³, Pramod S Ingaleshwar⁴, Sharan J Shetty⁴
¹ Department of Oral Pathology and Microbiology and Forensic Odontology, School of Dental Sciences, Krishna Institute of Medical Sciences, Deemed University, Karad, Satara, Maharashtra, India
² Department of Oral Medicine and Radiology, School of Dental Sciences, Krishna Institute of Medical Sciences, Deemed University, Karad, Satara, Maharashtra, India
³ Department of Public Health Dentistry, School of Dental Sciences, Krishna Institute of Medical Sciences, Deemed University, Karad, Satara, Maharashtra, India
⁴ Department of Oral Pathology and Microbiology and Forensic Odontology, A.J. Institute of Dental Sciences, Mangalore, Karnataka, India

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Date of Web Publication

13-Nov-2013

Abstract

Piercing is a more prevalent ancient form of body art all over the world, recently popularity attained in Western society. For centuries, piercing was part of many cultures and religious rites. Ancient Egyptians pierced their navels to signify royalty, Roman centurions wore nipple rings as a sign of virility and courage and Mayans pierced their tongues for spiritual purposes, The Eskimos and Aleuts pierced the lips of female infants as part of a purification ritual and the lower lip of the boys as part of passage into puberty. It is that apparent that oral piercings are becoming much more prevalent in today's society. Popular sites for body piercing include the ears, eyebrows, lips, nose, nipples, navel, penis, scrotum, labia, clitoris and tongue. Oral body art, as it is referred to, usually involves piercing of the tongue, cheeks, lips or uvula. The lip is the most commonly pierced site, but tongue piercing is becoming more prevalent. Due to increase in oral piercing, it is important for dental and medical professionals to have knowledge about piercings to educate their patients concerning risk factors, complications and optimal homecare for piercings.

Keywords: Complications, lip, oral piercing, piercing, tongue

How to cite this article:
Pramod R C, Suresh K V, Kadashetti V, Shivakumar K M, Ingaleshwar PS, Shetty SJ. Oral piercing: A risky fashion. J Educ Ethics Dent 2012;2:56-60

How to cite this URL:
Pramod R C, Suresh K V, Kadashetti V, Shivakumar K M, Ingaleshwar PS, Shetty SJ. Oral piercing: A risky fashion. J Educ Ethics Dent [serial online] 2012 [cited 2023 Oct 4];2:56-60. Available from: https://www.jeed.in/text.asp?2012/2/2/56/121257

Introduction

Body piercing is defined as penetration of jewelry into openings made in body areas such as eyebrows, helix of the ears, lips, tongue, nose, navel, nipples and genitals. ^{[1],[2],[3],[4]} Piercing is a cultural practice or tradition in various civilizations dating back to antiquity. In the current Western culture, the decision to pierce is often a personal statement representing fashion, risk and daring. There usually is no formal religious, tribal or ornamental purpose. Countries such as United states of America and United kingdom reported carrying out at least 30,000 new piercings per year in the late 1990s. ^[5],[6],[7] Of significance to the dental profession is the increasing popularity of tongue and lip piercings, which is the insertion of jewelry into soft oral tissues including the lips, cheeks and tongue [Figure 1]. ^[8] Rarely, it may also involve other oral sites, like the uvula [Figure 2]. ^[9] It appears that the tongue is the most prevalent oral piercing site, generally pierced in the midline and just anterior to the lingual frenum. ^[10]

Figure 1: Tongue piercing

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Figure 2: Uvula piercing

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Materials Used in Piercing

In ancient years materials used were stones, bones or ivory. Overall, there has been a decrease in many of these cultural practices with the introduction of Christian influences. ^[11] Nowadays, hypoallergenic and non-toxic materials are used for piercing jewelry, e.g., 14 or 18 K gold, titanium, stainless steel, niobium, tygon, acrylic, stone, wood, bone or ivory 13-15 for reasons of "religious, sexual, tribal or marital significance." ^[12]

Types of Oral Piercing

There are several types of oral piercings; however, piercing the tongue is the most common practice. There are two types of tongue piercing, dorsoventral and the dorsolateral. Dorsoventral is most commonly practiced and safer procedure. In dorsoventral piercing, the jewelry is inserted from the dorsal to the ventral surfaces of the tongue. This piercing is commonly located in the middle of the tongue and major blood vessels must be avoided during the procedure. Some individuals may choose to have multiple dorsoventral piercings. ^[11]

The dorsolateral piercing is not a safe procedure due to the vascularity of the tongue; therefore, dorsolateral piercing is not usually performed by professional piercers. In the dorsolateral piercing, both spheres of jewelry are on the dorsum of the tongue at the lateral borders and located about halfway in an anteroposterior direction. The barbell is placed dorsally, curves down toward the ventral side of the tongue and resurfaces at the dorsal aspect. ^{[12],[13],[14]}

Four types of piercing jewelry are applied in the oral area. One type is the labret, a bar with ball [Figure 3], disc or point at one end and flat closing disc at the other. Another type is the barbell, a straight or curved bar with balls at each end. Barbells are the most popular form of jewelry placed in the dorsoventral piercing. A third type is an unclosed ring with a ball at one or both ends [Figure 4]. In a fourth type, two components of the stud are held together by a magnetic force 10-fold greater than that of a conventional magnet. ^{[15],[16],[17]}

Figure 3: Piercing jewelry bar with ball

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Figure 4: Piercing jewelry, unclosed ring with a ball at one ends

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Another popular oral piercing is the labret, which refers to piercing sites of the lip. One type is placed above the labiomental groove and centered underneath the vermillion border. This piercing site is reminiscent of the lip piercing of the Suya tribe of Brazil and peoples of Africa. ^[18]

Complications and possible adverse consequences of oral piercing

Pain and swelling
Hemorrhage
Nerve damage
Inflammation
Localized infections
Trauma to the gingiva
Bacteremia
Ludwig's angina
Cracked or fractured teeth
Aspiration or ingestion
Increased salivary flow and impediment of speech
Plaque and calculus deposition
Transmission of organisms
Anaphylactic reactions
Localized tissue overgrowth
Systemic infections.

Pain and swelling

As with any wound, tongue splitting and piercing can cause pain and swelling. The swelling can be so severe that it interferes with breathing and swallowing. ^[19]

Hemorrhage

The tongue is vascular; therefore, the lingual artery and vein will bleed during the piercing procedure. If hemorrhage occurs, immediate action should be taken to avoid profuse blood loss. ^[19]

Nerve damage

The dorsolateral and the dorsoventral nerve can be damaged during tongue piercing. If this occurs, irreversible damage to the sense of taste or motor effects can be affected. ^{[18],[19],[20]}

Inflammation

Inflammation of the pierced area occurs immediately after the piercing procedure and can last for 3-5 weeks. The sub mental and sub mandibular lymph nodes may also become enlarged. ^[19]

Localized infections

Localized infection can occur if proper aftercare is not practiced. If an infection does not respond to treatment within 1 or 2 days, patient should seek medical attention. Spread of these infections to the mediastinum or cavernous sinus can be life-threatening. ^[1],[20]

Trauma to the gingiva

This can occur when tongue piercing rubs against the gingiva causing trauma to the tissue. ^[18],[19]

Bacteremia

An infection can occur both during and after the piercing procedure. It is spread when bacteria is introduced into the bloodstream. Furthermore, it can spread from a localized infection. The symptoms consist of fever, chills and red streaked appearance in the pierced site. ^[20]

Ludwig's angina

This is a serious infection due to compromise of the airway and can be life-threatening. Symptoms consist of painful swelling of the tongue, difficulty swallowing, breathing or speaking. ^[21]

Cracked or fractured teeth

This occurs when patient speaks or eats and the barbell that is inserted in the tongue strikes the teeth. Both anterior and posterior teeth can be affected depending on the size of barbell. ^[19]

Aspiration or ingestion

If jewelry becomes loose, patient can aspirate or swallow the jewelry, which can result in either respiratory or gastric distress. ^[20],[22]

Increased salivary flow and impediment of speech

Increased salivary flow occurs because a foreign object has been introduced into the oral tissues. The presence of piercing jewelry in the mouth, especially on the tongue, commonly hampers chewing, phonation and speaking and distorts the pronunciation of certain sounds, e.g., "s," "sh," "th", "ph," "t" or "v." ^[22]

Plaque and calculus deposition

A greater presence of plaque can be produced at the site of oral piercings due to the difficulty of maintaining hygiene and retention of food remains, creating an ideal environment for a large accumulation of plaque and calculus. Plaque accumulation can produce halitosis and possible infection. Thus, oral piercings have been associated with gingivitis, ^[22] which requires the presence of bacteria in plaque for its onset, although factors related to microorganisms and host predisposition also affect this pathogenesis. ^[23]

Transmission of organisms

Piercing of oral sites is associated with a high risk of infection because of the large and diverse oral micro flora present and the possible transmission of organisms such as human immunodeficiency virus, hepatitis B and C, herpes simplex virus, Epstein-Barr virus, Staphylococcus aureus, A group Streptococcus, Pseudomonas aeruginosa, Erysipelas, β-hemolytic Streptococcus, ^[17] tetanus ^[11] and candida. ^{[20],[21],[22]}

Anaphylactic reactions

Anaphylactic reactions can be produced by some of the materials inserted, e.g., nickel, the metal that causes most contact allergies. The most widely reported allergic reaction in piercing is contact dermatitis produced by nickel, chromium or nickel-cobalt. ^[23],[24] In the mid-1990's, the European Union issued a directive to limit the amount of nickel in all products in direct contact with human tissue, with a limit of 0.05 g for the nickel used in oral piercing jewelry. It also recommended that gold used for this purpose should be at least 14-18 K. ^[24]

Localized tissue overgrowth

Among later complications following oral piercings, traumatic injuries to the mucosal surfaces at the piercing site have been documented. These include enlargement of the piercing hole, chemical burns associated with excessive aftercare paresthesia, sialadenitis, ^[19] lymphadenitis, sarcoid-like foreign-body reactions, granulomas and scar tissue formation at the piercing site after the removal of a labret or barbell. Moreover, barbell shanks that are too short may lead to localized tissue overgrowth, with the mucosal surface of the tongue healing over the barbell. Lingual piercings that become embedded in the ventral or dorsal surface of the tongue have been reported. In contrast, an excessively long shank may allow the barbell to move in the tissue, which may lead to an inflammatory hyperplasic tissue reaction and the accumulation of dental plaque and calculus on the shank. Intraoral piercings have also been implicated in the formation of hypertrophic keloid tissue. Keloid lesions are formed when unaffected tissue infiltrates the piercing, they are characterized by the production of an interstitial mucinous material on the collagen of connective tissue. ^[3],[19]

Systemic infections

The open wound at the pierced site may also be a source of systemic infectious complications as it may allow microorganisms to enter the bloodstream. This may lead to subsequent infection of other organs by microorganisms inhabiting the oral cavity. Recurrent bacteremias may constitute a threat long after tongue piercing, especially in immune compromised people. ^[25] Rheumatic heart disease, congenital deformities, hypertrophic cardiomyopathy, mitral valve prolapse associated with murmur and mitral calcification have been cited as predisposing factors. Infective endocarditis may be caused by metastatic oral bacteria. Once bacteria have entered the bloodstream, the subsequent colonization of the endocardium typically affects valves with congenital or acquired dysfunction. Infective bacterial endocarditis following body piercing is relatively rare. However, over the past few years, an increasing number of case reports have described episodes of infective endocarditis following tongue piercings. ^{[26],[27],[28],[29],[30]} A recent survey investigating the practice of tongue piercing revealed that few piercers are aware of the risk of bacterial endocarditis in certain categories of people. ^[31]

Piercing guidelines for infection control include

Using germicidal soap to clean the hands of the person who performs piercing and the area of the client to be pierced.
Wearing clean apparel and rubber gloves.
Tools and equipment shall be sterilized by either the use of a dry heat.
Sterilizer or steam pressure treatment in an autoclave.
Keeping the piercing studio or temporary location in a sanitary condition.
Person who performs piercing shall sterilize tools and equipment used on one client before using them on another client.
All needles and instruments shall be kept in a clean, dust free and air tight container when not in use.

Post care instruction

Patient should use a clean finger or spoon to place the food, small bites are recommended, should chew slowly to avoid biting the jewelry. Tongue piercings may be removed while eating after the piercing has healed to reduce the risk of biting on jewelry, once the piercing site heals, patient should replace the longer bar with a shorter bar that has acrylic ends to reduce the risk of trauma to teeth and supporting structures. With a lip or cheek piercing, patient should avoid opening too wide because the jewelry may cause trauma to teeth or gingiva as tissues are stretched and tightened. Patient should use a new toothbrush following piercing to limit bacteria in the mouth from the old tooth brush, recommended to brush lightly in pierced and surrounding area. As the piercing heals, ideally, jewelry should be cleaned after every meal.

Patient education

This includes advising on safety and health issues as well as obtaining and maintaining optimal oral hygiene during and after the procedure. It is important for oral health-care professionals to inform and educate prospective and new piercees. An excellent brochure for patients has been produced by the Association of Professional Piercers and a copy can be downloaded from the association's web site at: http://www.safepiercing.com/.

Management of the dental patient

Patient presenting with an oral piercing will not require any special considerations by the oral health-care professional during treatment. However, when jewelry removal is indicated a well-prepared dental team should have the necessary supplies available in the office. This is important because when oral piercing jewelry is removed, closure may begin to occur in a short time. During exposure of radiographs, it is often necessary to remove jewelry. For panoramic radiographs, all jewelry should be removed above the neck. Cheek and labret jewelry should be removed for periapicals and bitewing radiographs because of their location in relation to film placement and tube head. The need for jewelry removal during local anesthesia is at the discretion of the oral health-care professional. The mandibular block is one injection, for which jewelry removal may be prudent. When the tongue is anesthetized, there is increased possibility for tooth damage until the anesthesia has completely disappeared.

Microbiology in oral piercing area

Bacterial infection after tongue piercing was described by Scully and Chen as early as 1994. ^[32],[33] The piercing procedure exposes the pierce to a high risk of infection because the oral cavity harbors a huge amount of bacteria. ^[34] The high vascularity of the area and the possible transmission of diseases, such as hepatitis B, hepatitis C and acquired immune deficiency syndrome are further aspects to be considered. ^[35],[36]

Dental bio film harbors a great variety of different microorganisms and today it is well-recognized that some of these bacteria, e.g., aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Tannerella forsythia and Treponema denticola, are frequently detected in periodontal diseases. Wearing tongue jewelry over an extended period of time may result in the colonization of periodontopathogenic bacteria at the piercing site in the absence of appropriate oral hygiene practices. ^[32]

Piercings versus saliva formation

Several studies have confirmed that piercings in the oral cavity can stimulate salivary flow (sialorrhea), increased salivary flow occurs because a foreign object has been introduced into the oral tissues. Thus, Escudero-Castaño N et al. observed increased salivary flow in 63% of their study. ^[17]

Conclusion

Piercing invades subcutaneous areas and has a high potential for infectious complications. The number of case reports of endocarditis associated with piercing is increasing. Tongue and lip piercings represent a significant risk for direct and indirect damage to soft and hard oral tissues. Although much less prevalent, lethal systemic infections may also occur. Considering the growing popularity of oral piercings, dental professionals should be aware of the potential complications associated with this practice and be able to identify those at high risk for adverse outcomes. Together with parents and educators, dental professionals should play an active role in warning patients of the serious consequences of oral piercing and should provide appropriate guidance.

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