|Year : 2013 | Volume
| Issue : 2 | Page : 84-91
Oral piercing: Style statement or a state of disharmony?
Neelam Khalia1, Gayathri Gunjiganur Vemanaradhya2, Dhoom Singh Mehta2
1 Department of Periodontics, NIMS Dental College and Hospital, Jaipur, Rajasthan, India
2 Department of Periodontics, Bapuji Dental College and Hospital, Davangere, Karnataka, India
|Date of Web Publication||4-Jul-2014|
Department of Periodontics, NIMS Dental College and Hospital, Shobha Nagar, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
Oral piercing is a practice that was done even in the before Christ era, but the designs and purposes are changing with time. These days, it is mainly used as a style statement and for religious reasons. Although it aids in marking the identity of a person, but at the same time if not done with precision, then it can lead to various disastrous effects as well. This review highlights the various facets of oral piercing, including its history, designs, procedure, complications, precautions to be taken for a patient bearing oral piercing jewelry and the current status.
Keywords: Gingival recession, jewelry, lip piercing, tongue piercing, tooth fracture
|How to cite this article:|
Khalia N, Vemanaradhya GG, Mehta DS. Oral piercing: Style statement or a state of disharmony?. Int J Oral Health Sci 2013;3:84-91
| Introduction|| |
Oral piercing usually refers to the piercing of a part of the oral cavity for the purpose of wearing jewelry in the created opening. Oral and perioral piercing has long been practiced for religious, cultural, sexual or identity reasons.  Now, it has become a highly acceptable fashion statement in our society. Like most of the advancements, this is also like a two-edge sword, although it aids in self-expression, but at the same time it is associated with many risks as well. To take the maximum benefit of it, we the health care practitioners, the general public and the piercing professionals should be aware of all the pros and cons of the same.
| History|| |
Oral piercing is not something new. Human beings are into the piercing practice since 1500 B.C, although the objectives, designs and procedures have been undergoing changes with time. It has been practiced in various parts of the world. Body piercing in general is mentioned even in the bible. History of oral piercing specifically began from the jungle tribes in South America, Africa and Indonesia, which are considered to be the oldest human races. Tongue piercing began in America, and it was a huge ritual for the Mayans, Aztecs, Tlingit and the Haida tribes. While they believed it pleased their gods, the more recent piercings of the tongue are done to derive oral sexual pleasure. Fakirs and Sufis from the Middle East and Asia also practice tongue piercing. Eskimos use labret inserted into the lower lip as a symbol of passage to adulthood in boys and as an act of purification in girls. Ethiopian men and women have also been found to be using various facial piercings. They believe that the lip plate in the women help to gain social status and command a higher bridal price. In Africa, many tribal woman wear lip plates called "Pelele" in their upper lip for sexual reasons. Piercing the lips, especially with a ring, is a tradition of only two tribes, the Dogon and the Nubas of Africa. The Aztecs and the Mayans pierced their lips with labrets while the Makololo tribes wear lip plates. The piercing of lips, cheek or tongue was also a traditional practice in Hindu and Chinese cultures. , This is an ancient practice in some places of India, like West Bengal, Karnataka, etc., where it is conducted every year as a ritual. In the event, the iron rod is pierced through the tongue/cheek and removed once the believer makes round of the village collecting offerings, which usually takes about an hour.
| Present Scenario|| |
These days, piercing is used more often as a form of self-expression rather than for representing the traditions and beliefs. Majority of people do so for esthetic reasons. This trend has been supported by many popular celebrities, including singers like Britney Spears, Ashley Scott, Christina Aguilera, etc. and actresses like Drew Barrymore, Sonam Kapoor (Indian), etc. A perception of reversibility with oral and body piercings, as compared with tattoos, has also added to their growing popularity. Now, it has become an acceptable form of body art because of the increasing demand. The media is also playing a great role in increasing its acceptance among the common public.
| Prevalence|| |
A recent systematic review revealed that oral and/or peri-oral piercings are observed in around 5.2% of young adults. It is found to be four times higher among females than males, and more in athletes than in nonathletes.  The most common age to receive it is between 18 and 30 years. Although the number of people practicing oral piercing has increased drastically, there are still no strict rules and regulations for this field. , In spite of getting so much popularity, there is lack of scientifically trained people in this field. Most of them are trained either through the Internet, videos, books or trial-and-error method. Major risks after oral piercing arise because of such informal training and improper sterilization protocol during the procedure.
| The Piercing Procedure|| |
Almost all oral piercings are performed as a straight piercing, i.e. they do not need the boring needle to be bent unlike other body piercing sites. The majority of sites are chosen based on the statistical absence of major vessels or nerves. Once a site is chosen, it is marked and the tissue is grasped with sponge forceps [Figure 1]. The initial piercing of tissue is commonly performed by using a 14-gauge boring needle, following which an identical-sized piece of jewelry is used to push the needle so that only the jewelry remains inside and the needle comes out from the tissue. As the piercers are not licensed medical professionals, anesthesia is not often used for the procedure. The healing period for the pierced site may vary from 3 to 12 weeks, depending on the vascularity of the site and other factors that affect the healing process. 
| Types Of Oral Jewelry Designs|| |
The most commonly used intraoral jewelry are of two types, i.e. piercing and nonpiercing.
Piercing type of oral jewelry
- Barbell: A straight or curved bar with balls at each end [Figure 2]
- Labret: A bar with ball/disc/cone point at one end and flat closing disc at the other [Figure 3].Barbell and labrets may utilize either internally or externally threaded heads
- Captive bead ring: Unclosed ring with a ball either at one or both the ends [Figure 4].
The piercing procedure for these jewelries is invasive and painful, and if not done with perfection then might be associated with various complications.
Nonpiercing type of oral jewelries
- Magnetic jewelry: Two components of the stud are held together by a magnetic force [Figure 5]
- Tooth jewelry: Tooth jewelry is held over the tooth with the help of light cure composites after application of etchant and bonding agent. It mainly includes gems, twinkles that are pure gold or other precious stones like diamond, rubies, etc. [Figure 6].
The procedure to utilize these jewelries is painless and usually not associated with any risk of infection. They are easily removable and, at the same time, add more attractiveness and sparkle to the smile, but their stability is uncertain. The cost of jewelry may vary widely depending on the style and material used for its design.
| Intraoral and Perioral Piercing Sites|| |
A vertical piercing through the midline of the tongue, anterior to the lingual frenum, is the most common oral piercing site [Figure 7].  The tongue may also be pierced multiple times, off-center or horizontally [Figure 8]. These alternative sites increase the risk of nerve damage or hemorrhage. A more extreme form of modification to the piercing of tongue involves the separation of the anterior portion into two separate halves [Figure 9]. The formation of a bifid tongue may be done with a scalpel or by inserting a nylon line into a piercing site and then twisting the line over a period of weeks, until the line has moved completely through the anterior portion of the tongue. Tongue piercings require the initial barbell, long enough to allow for postpiercing swelling to occur. Once the swelling decreases (usually within 2-4 weeks), a piece of downsized jewelry will be inserted as a replacement to avoid complications.
The lip is the second most frequently pierced oral site generally in the midline, which is also called as Monroe piercing [Figure 10], but may also be pierced off-center. Captive-bead rings are the preferred type of jewelry over labrets as they allow for postoperative swelling and are easier to clean than labrets. Once the swelling has subsided, the ring may be replaced with a labret if desired. The lower lip is usually pierced through the mucosal tissue just beneath the vermillion border, and the length of the jewelry depends on the thickness of the tissue being pierced. 
The frena often pierced are mandibular lingual frenum and maxillary labial frenum [Figure 11]. The buccal frena are not pierced often. Piercing is done through the mucosal fold present beneath the tongue for the lingual frenum and beneath the lining mucosa of the upper lip between the central incisors for labial frenum. These piercings are relatively simple and heal quickly. Aftercare for lingual frenum piercings can be more complicated as the wound will come in contact with anything that enters the mouth. Both ring and barbell style jewelry can be worn in these piercings. ,
Uvula is the quite infrequently pierced site due to the difficulty in accessing the anatomy for the procedure, fear of increased potential for jewelry aspiration and interference with normal functional activities like swallowing. Commonly used jewelry is captive bead ring [Figure 12]. 
Cheek piercing is generally done to imitate dimples [Figure 13]. It involves penetration of the cheek from the facial tissue into the oral cavity. The usual placement of jewelry is symmetrical on either side of the face. Commonly used jewels are barbells or labrets. 
Although tooth pierce has been tried before but is quite rarely done due to various undesired consequences following imprecise performance of the procedure. It is usually done on the incisal third of the maxillary anterior teeth and ring design jewel is commonly used for the same [Figure 14]. 
| Complications of Oral Piercing|| |
Several complications have been found to be associated with oral piercing practice, although they rarely lead to lethal outcome but they do increase the burden on health services. ,
Damage to the nearby anatomical vital structure
If a practitioner is not aware of the adjacent anatomic structure, it can lead to damage of the neighboring vital structures like lingual artery/vein or nerve, frenum musculature, tongue muscles, etc. Tooth piercing if not done carefully can involve the pulp, leading to peri-apical pathology, or the tooth may become nonvital.
Transmission of disease
This can occur due to the use of contaminated instruments for the invasive piercing procedure. The organisms that can get transmitted are Hepatitis B and C virus, the herpes simplex virus, HIV, etc. 
The risk of infection is increased due to the presence of bacteria in the mouth and those that can be additionally introduced during the piercing procedure. Wrong technique and poor sterilization protocol can lead to prolonged bleeding and delayed wound healing. Both local and systemic bacterial infections can occur as a side-effect of tongue piercing. , One case of hypotensive collapse has been reported because of excessive bleeding after tongue piercing.  Endocarditis has also been found to be associated with tongue piercing. ,,, The use of rusted or improperly sterilized instruments for the procedure can cause infections like tetanus.  The infections induced from oral piercing can even lead to life-threatening problems, like Ludwig's angina.  Fungal infection like yeast infection can also occur due to excessive cleansing done to keep the piercing site hygienic. Cases of cerbellar abscess  and chorioamnionitis  has also been reported in patients with tongue piercing.
Allergic reaction to metal
Silver coatings and other finishing on poor-quality jewelry may wear off, resulting in the exposure of the underlying material, which can delay wound healing or create an allergic sensitivity in patients. This problem is seen more commonly in the younger age group due to their limited financial resource.  The jewelry itself made of biological inert material such as surgical stainless steel, niobium, 14K or 18K gold or titanium should be used to avoid complications.
Aspiration of jewelry
Till now, no such case has been officially reported. One study did report the ingestion of imitation piercings held onto the tongue or lip by magnets, resulting in a near-fatal surgical complication. Commonly, such practices were being used by children, in an effort to imitate trends they perceived as desirable within the adult community.  It may lead to life-threatening conditions.
Damage to tooth structure (chipped or cracked tooth)
Damage to tooth structure can occur either due to accidental or intentional biting over the barbell head. Lingual barbells have been found to be associated with cracked tooth, including both anterior teeth and posterior molar and premolar cusp tips.  This injury to teeth caused by tongue jewelry may cause cracks and fractures in teeth; hence, it is also called as wreckling ball fracture.  Damage to the buccal surface of both the maxillary and the mandibular posterior teeth and their periodontium can be caused by barbell and labrets used for cheek piercing. The factor most closely associated with dental fractures is the length of the barbell. In case of tongue piercing, the length of an ideal barbell should be just greater than the thickness of the tongue. Yet, many individuals choose to keep the longer initial barbell as it is more amusing to move the longer one through the tongue a greater distance and to prevent the expenses of buying a shorter one.  A recent study found that 47% of individuals wearing a lingual barbell for 4 years or more exhibited damage to the tooth structure.  Athletes have been reported with greater risk for damage to their teeth and tissues because of stress, and should be advised to remove their piercings during sports. 
Damage to soft tissue
Gingival recession on lingual aspect of mandibular incisors have been reported due to lingual barbells [Figure 15].  More than 50% of individuals wearing long barbells for a period greater than 2 years on the tongue were found to exhibit gingival stripping.  Lip labrets or rings, specifically the one placed deeper in the sulcus, are believed to increase the chance for gingival recession.  Individuals who habitually play with their oral jewelry by rubbing them against their teeth and gingiva are most likely to experience this type of damage. To date, the association between soft tissue damage and the size of the labret stud or lingual barbell has not been evaluated. Barbell stem length in case of tongue piercing appears to differentially affect the prevalence of recession and chipping. 
Mild tissue hyperplasia may be anticipated around the pierce during the initial phase of healing, but severe tissue hyperplasia is definitely a matter of concern. A case has been reported with jewelry engulfed in the tissue to the point that surgical excision was the only viable option to release the jewelry.  For this reason, longer lingual barbells and lip rings instead of labrets are generally used following an initial piercing.
Interference with normal oral function
This can occur mostly in case of uvula and tongue pierce. They can interfere with mastication and swallowing, leading to dysphagia. 
Oral jewelry may interfere with radiographic diagnostic techniques, particularly panoramic radiographs. Patients requiring this form of X-ray should remove their jewelry prior to radiographic exposure. Patients often express fears that their piercing site will close up immediately upon removal of their jewelry. If reassurance is not sufficient for the patient, then a modified nylon may be used to maintain a patent opening.  Cone-shaped tissue expander can also be used for re-opening of the closed pierce. Gingival recession has been reported almost equally for tongue and lip piercing, but dental defects have been found more commonly with tongue piercing. , The duration of oral piercing has also been found to be associated with extent of dental defects, gingival recession, attachment loss and probing depth of adjacent teeth. 
Fashion statement for youngsters is beyond imagination without limitation. Although oral piercing cannot be inhibited, it can be performed with strict principles followed by the piercer, wearer and oral health care practioner. Because of its enormous potential to cause complications, the American Dental Association and American Academy Pediatric Dentistry strongly opposes the practice of intraoral/perioral piercing and tongue splitting. ,
| Precautions To Be Taken By The Oral Piercing Wearer|| |
Patients should undergo the piercing procedure by a licensed/well-trained person only. They should wear only good quality jewelry and imitation piercing jewelry should be avoided. Proper oral hygiene should be maintained along with thorough cleaning of the jewelry. Clicking, tapping or rubbing on the oral jewelry should be avoided. The patient should visit the dentist regularly for checkup and contact them immediately if any discomfort, locally or systemically, is felt following the oral piercing.
| Role of Oral Piercing Practioners|| |
The practitioner should obtain informed consent regarding the pros and cons of oral piercing by the patient. They should be aware of the adjacent vital anatomical structures. Local anesthesia should be used whenever required, and should follow strict infection control regime during the procedure. Pre- and post-antimicrobial therapy should be considered as required.
| Role of The Oral Health Provider|| |
Most of the piercing professionals lack training of the procedure and sterilization protocols to be followed. As there is a lack of strict rules and regulations regarding the profession, the oral health care providers should be aware of the relevant complication and their management.  They can provide education and motivation regarding harmless piercings, oral hygiene maintenance and possible complications.  Use of barbells with an acrylic head should be encouraged to prevent the chipping of tooth. If a longer barbell is noticed in a patient with tongue pierce after complete healing of the site, then they should be encouraged to replace it with a shorter one. Any signs of infection should be dealt with as quickly as possible and a recall visit appointment card should be maintained to streamline the patient regularity.
| Conclusion|| |
Oral piercing is one of the oldest and most interesting forms of body modification, yet the explanations for piercing are as varied as the cultures they come from. Now it is crystal clear that it is not just a style statement but can also lead to various complications, including both oral and systemic, among which few of them can be lethal too. Hence, patients with an oral pierce should visit the dentist for regular checkup more frequently than their counterparts. We being the dental surgeons should be aware of all the potential risks and, at the same time, should make the public also aware of the same. Although the oral piercing practice has been opposed in few countries, if such patients are encountered, they should be encouraged to maintain proper oral hygiene and any complication found should be dealt as soon as possible. We can play a role not only in improvising the smile of a patient but can also help in eliminating those elements, which can lead to disharmony in the healthy smile of a patient. We can help to make the oral piercing a purely healthy practice.
| References|| |
|1.||Huber MA, Terezhalmy GT, Moore WS. Oral/perioral piercing.Quintessence Int 2003;34:722-3. |
|2.||Brennan M, O′Connell B, O′Sullivan M. Multiple dental fractures following tongue barbell placement: A case report. Dent Traumatol 2006;22:41-3. |
|3.||Berenguer G, Forrest A, Horning GM, Towle HJ, Karpinia K. Localized periodontitis as a long-term effect of oral piercing: A case report. Compend Contin Educ Dent 2006;27:24-8; quiz 36. |
|4.||Hennequin-Hoenderdos NL, Slot DE, Van der Weijden GA. The prevalence oforaland peri-oralpiercings in young adults: A systematic review. Int J Dent Hyg 2012;10:223-8. |
|5.||Tweeten SS, Rickman LS. Infectious complications of body piercing. Clin Infect Dis 1998;26:735-40. |
|6.||Folz BJ, Lippert BM, Kuelkens C, Werner JA. Hazards of piercing and facial body art: Report of three patients and literature review. Ann Plast Surg 2000;45:374-81. |
|7.||Boardman R, Smith RA. Dental implications of oral piercing. J Calif Dent Assoc 1997;25:200-7. |
|8.||Singh A, Tuli A. Oralpiercings and their dental implications: A mini review. J Investig Clin Dent 2012;3:95-7. |
|9.||Randall JA, Sheffield D. Just a personal thing? A qualitative account of health behaviours and values associated with bodypiercing. Perspect Public Health 2013;133:110-5. |
|10.||Pejcic A, Kojovic D, Mirkovic D. Oralpiercingand its complications in two Serbian youths: A case report and review of the literature. West Indian Med J2012;61:838-43. |
|11.||Yee LJ, Weiss HL, Langner RG, Herrera J, Kaslow RA, van Leeuwen DJ. Risk factors for acquisition of hepatitis C virus infection: A case series and potential implications for disease surveillance. BMC Infect Dis 2001;1:8. |
|12.||Batiste C, Bansal RC, Razzouk AJ. Echocardiographic features of an unrupturedmycotic aneurysm of the right aortic sinus of Valsalva. J Am Soc Echo cardiogr 2004;17:474-7. |
|13.||Dubose J, Pratt JW. Victim of fashion: Endocarditis after oral piercing. Curr Surg 2004;61:474-7. |
|14.||Hardee PS, Mallya LR, Hutchison IL. Tongue piercing resulting in hypotensive collapse. Br Dent J 2000;188:657-8. |
|15.||Kloppenburg G, Maessen JG. Streptococcus endocarditis after tongue piercing. J Heart Valve Dis 2007;16:328-30. |
|16.||Lick SD, Edozie SN, Woodside KJ, Conti VR. Streptococcus viridansendocarditis from tongue piercing. J Emerg Med 2005;29:57-9. |
|17.||Tronel H, Chaudemanche H, Pechier N, Doutrelant L, Hoen B. Endocarditis due to Neisseria mucosaafter tongue piercing.Clin Microbiol Infect 2001;7:275-6. |
|18.||Yu CH, Minnema BJ, Gold WL. Bacterial infections complicating tongue piercing. Can J Infect Dis Med Microbiol 2000;21:e70-4. |
|19.||Dyce O, Bruno JR, Hong D, Silverstein K, Brown MJ, Mirza N. Tongue piercing. The new "rusty nail"? Head Neck 2000;22:728-32. |
|20.||Shacham R, Zaguri A, Librus HZ, Bar T, Eliav E, Nahlieli O. Tongue piercing and its adverse effects. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:274-6. |
|21.||Martinello RA, Cooney EL. Cerebellar brain abscess associated with tongue piercing. Clin Infect Dis 2003;36:e32-4. |
|22.||Jadhav AR, Belfort MA, Dildy GA 3 rd . Eikenella corrodens chorioamnionitis: Modes of infection? Am J Obstet Gynecol 2009;200:e4-5. |
|23.||Knox K. The potential complications of intra-oral and peri-oral piercing. Dental Health 2002;41:10-4. |
|24.||Dibart S, De Feo P, Surabian G, Hart A, Capri D, Su MF. Oral piercing and gingival recession Review of the literature and a case report. Quintessence Int 2002;33:110-2. |
|25.||Mayers LB, Judelson DA, Moriarty BW, Rundell KW. Prevalence of body art (body piercing and tattooing) in university undergraduates and incidence of medical complications. Mayo Clin Proc 2002;77:29-34. |
|26.||Stirn A. Body piercing: Medical consequences and psychological motivations. Lancet 2003;361:1205-15. |
|27.||Zaharopoulos P. Fine-needle aspiration cytology in lesions related to ornamental body procedures (skin tattooing, intraoral piercing) and recreational use of drugs (intranasal route). Diagn Cytopathol 2003;28:258-63. |
|28.||Geddes DA, Jenkins GN. Intrinsic and extrinsic factors influencing the flora of the mouth. Soc Appl Bacteriol Symp Ser 1974;3:85-100. |
|29.||Campbell A, Moore A, Williams E, Stephens J, Tatakis DN. Tongue piercing: Impact of time and barbell stem length on lingual gingival recession and tooth chipping. J Periodontol 2002;73:289-97. |
|30.||Sardella A, Pedrinazzi M, Bez C, Lodi G, Carrassi A. Labial piercing resulting in gingival recession. A case series. J Clin Periodontol 2002;29:961-3. |
|31.||McNamara CM, McNamara TG, Field D, Ryan D. "Hidden tongue jewelry". Singapore Dent J 2001;24:51-3. |
|32.||Folz BJ, Lippert BM, Kuelkens C, Werner JA. Jewelry-induced diseases of the head and neck. Ann Plast Surg 2002;49:264-71. |
|33.||Peticolas T, Tilliss TS, Cross-Poline GN. Oral and perioral piercing: A unique form of self-expression. J Contemp Dent Pract 2000;1:30-46. |
|34.||Kapferer I, Beier US. Lateral lower lippiercing: Prevalence of associated oral complications: A split-mouthcross-sectional study. Quintessence Int 2012;43:747-52. |
|35.||Giuca MR, Pasini M, Nastasio S, D′Ercole S, Tripodi D. Dental and periodontal complications of labial and tongue piercing. J Biol Regul Homeost Agents 2012;26:553-60. |
|36.||Plessas A, Pepelassi E. Dental and periodontal complications of lip and tongue piercing: Prevalence and influencing factors.Aust Dent J 2012;57:71-8. |
|37.||For the dental patient: The piercing truth about tongue splitting and oral jewelry. J Am Dent Assoc 2012;143:814. |
|38.||Bone A, Ncube F, Nichols T, Noah ND. Body piercing in England: A survey of piercing at sites other than earlobe. BMJ 2008;336:1426-8. |
|39.||Stein T, Jordan JD. Health considerations for oral piercing and the policies that influence them. Tex Dent J 2012;129:687-93. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]