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Endod Dent Traumatol 2000; 16: 232237 Copyright C Munksgaard 2000

Printed in Denmark . All rights reserved


Endodontics &
Dental Traumatology
ISSN 0109-2502
Case report
Tongue piercing and associated oral and
dental complications
De Moor RJG, De Witte AMJC, De Bruyne MAA. Tongue R. J. G. De Moor,
piercing and associated oral and dental complications. Endod Dent A. M. J. C. De Witte,
Traumatol 2000; 16: 232237. C Munksgaard, 2000. M. A. A. De Bruyne
Department of Operative Dentistry and
Endodontology, School of Dentistry, University
Abstract The insertion of metal objects into intraoral and perioral
Hospital, University of Gent, Gent, Belgium
sites is growing in popularity. However, there are numerous oral and
dental complications associated with tongue piercing. Fifteen pa-
tients with tongue piercings (pierced in the body of the tongue,
anterior to the lingual frenum) attending the dental ofce of the
authors, with and without complaints, were clinically and radio-
graphically examined. The most common dental problem regis-
tered was chipping of teeth. Furthermore, two cracked teeth and
four teeth with cusp fractures were also seen. One case of selective
dental abrasion was registered. Trauma to the lingual anterior
gingiva was the most common gingival problem. A salivary ow
Key words: dental trauma; tongue piercing
stimulating effect was only reported by 2 of the 15 individuals. None
Roeland De Moor, Department of Operative
of the patients complained of interference with speech, mastication
Dentistry and Endodontology, School of Dentistry,
and swallowing. One case of galvanic currents produced by the ap-
University Hospital, University of Gent,
pliance was registered. On the basis of the registered data, we con-
De Pintelaan 185,
cluded that patients need to be better informed of the potential com-
B 9000 Gent, Belgium
Tel: 0032 9 240 40 00. Fax : 0032 9 240 38 51
plications associated with tongue and oral piercings, and that the
dental profession can serve this role. Accepted January 21, 2000
Piercing has been a custom of many civilizations for
thousands of years. It is known that piercing the body
has spiritual, aesthetic and sexual connotations (1).
Only during the last decade has the art of body pierc-
ing attained popularity in Western society (1, 2). Of
signicance to the dental profession is the recent in-
crease in intraoral piercings (3, 4), which is the inser-
tion of jewelry into soft oral tissues including the lips,
cheeks and tongue.
Tongue piercing is a form of oral body art that
presents a unique concern for the dental profession. A
review of medical and dental literature found limited
information regarding potential oral or dental compli-
cations. Moreover, the information is limited to the
ndings in individual case reports. Among these nd-
ings are: the transmission of systemic infections, such
as hepatitis B, tetanus and HIV (47); a Ludwigs an-
232
gina secondary to tongue piercing (8); hemorrhage
with great concern in medically compromised pa-
tients (9); changes of speech, swallowing and mastica-
tion after placement of the ornament (3, 5, 6, 10);
aspiration of parts of the jewelry (3); allergy to the
metals when the piercing is not of the best quality or
when it contains metals such as nickel (3, 5); trau-
matic injury to the teeth leading to chipping, fractur-
ing of teeth and restorations, and pulpal damage (3).
With the growing number of piercings (among
them also oral piercings) and being aware of the risks,
complications and dental implications asssociated
with such procedures, the oral situation in 15 patients
with tongue piercings is evaluated. A clinical screen-
ing of such a patient group has not yet been published
in the scientic literature. To support the obser-
vations, 3 particular cases are presented.
Tongue piercing-related oral complications
Table 1. Data on the oral implications of 15 tongue piercing cases
Complications/factors No. of cases*
Cases requiring immediate professional medical and dental treatment as a result of the piercings 6
Cases resulting in a split tooth with acute symptoms i.e. pain 1
Cases resulting in a cracked tooth with acute symptoms i.e. pain 1
Cases resulting in cracks with loss of tooth substance (cusp fracture) with acute symptoms 1
Cases resulting in cracks with loss of tooth substance (cusp fracture) without acute symptoms 3
Cases resulting in chipping of teeth 12
Cases resulting in tooth abrasion 1
Cases with galvanic currents produced by the appliance 1
Cases developing infection 1
Cases resulting in gingival injury 6
Cases with noticably increased salivary ow 2
Range of frequency of jewelry removal (never) 11
(once a day) 2
(twice a day) 2
* Average length of time pierced is 13.2 months.
Material and methods
The oral situation of 15 patients with tongue piercings
attending the dental ofce of the authors, with and
without acute symptoms, was clinically and radio-
graphically evaluated. Thirteen patients had a pierc-
ing of the barbell-type (a bar with 2 balls) and 2 pa-
tients had a piercing of the labrette-type (a ball on the
ventral site of the tongue and a at end on the dorsal
side of the tongue).
Objective features, such as visual damage to the
teeth, gingival injury, developing infection, noticably
increased salivary ow, and allergy to the metal, were
scored. The patients were also questioned about sub-
jective symptoms, such as the impairment of speech,
swallowing and mastication.
Results
Table 1 illustrates the data regarding the oral impli-
cations of tongue piercing. The average length of time
pierced was 13.2 months. Of the 15 patients 4 were
seeking immediate dental care due to cracked teeth
(2) or the loss of tooth substance due to a crack (2).
One of the latter was in combination with an exten-
sive and acute abcess of the right lower rst molar.
The other patients consulted the dentist for a regular
control. In this group there was also one patient who
complained of sensitivity in an upper left rst molar,
extensively restored with amalgam, each time there
was contact between the lling and the stud of the
barbell. Though they did not have any subjective
complaints, 3 other patients needed immediate dental
care to prevent further cracking of a tooth or further
loss of tooth substance.
Twelve of the cases indicated damage to the teeth
in the form of chipping and one in the form of ex-
treme abrasion of the second molars. Six cases re-
ported gingival injury. Only 2 patients developed no-
233
ticeably increased salivary ow. One patient reported
the development of an infection. Allergic reactions to
the metal were not seen. The frequency of jewelry
removal ranged from never to twice a day. The aver-
age time the jewelry was left out was 15 min, ranging
from 5 to 30 min. When the tongue piercing was re-
moved it was cleansed in all instances with chlorhex-
idine and one patient placed the piercing daily in hot
boiling water for 15 min. One patient had once swal-
lowed a part of the barbell.
Case report
Case 1
A 24-year-old man visited the dental ofce on an
emergency basis. His chief complaint was a mobile
upper left second molar which had become painful a
week earlier. Clinical and radiographical examination
revealed a mobile 27 with an occluso-distal amalgam
lling and a sinus tract mesial to the mesial root of
this tooth (Fig. 1). The tooth was percussion sensitive
but not temperature sensitive.
Fig. 1. Radiograph of the posterior teeth, with periradicular radio-
lucency around tooth 27.
De Moor et al.
Fig. 2. View on the mesial wall of the access cavity: the crack ends
in the pulp chamber oor.
It was decided to remove the amalgam lling and
to perform a root canal treatment. After removal of
the central part of the amalgam lling, a crack in the
mesial wall of the tooth ending in the pulp chamber
oor was seen (Fig. 2 and 3). It was therefore decided
to extract the tooth. After extraction of the tooth a
second distal crack ending in the furcation was also
seen (Fig. 4). On further information, it became clear
that the patient had been experiencing subjective
symptoms for more than one year, starting a few
weeks after the piercing with a moderate temperature
sensitivity and pain while biting.
Case 2
A 33-year-old male presented at the dental ofce for
a routine dental examination and professional oral
prophylaxis. During the intra-oral examination, a
pierced tongue was noted (Fig. 5). The piercing had
been performed more than one year earlier and there
had been no symptoms of infection.
The patient admitted to enjoying biting down on
the studs and frequently clacking, as loud as poss-
ible, the studs against the upper front teeth as a
234
Fig. 3. Clinical view of the crack in the mesial wall of tooth 27.
game with friends. He then expressed some concern
about the presence of some chipped teeth. He had
not been informed of the possible complications as-
sociated with tongue piercing.
An examination of his dentition revealed injury to
the second molars, which had considerable loss of
tooth substance (Fig. 6 and 7). The teeth showed a
selective abrasion of the coronal surface. Further-
more, the left central incisor showed a local loss of
substance at the incisal edge (Fig. 8), which was due
to selective biting on the bar of the barbell.
The patient was warned of the oral and dental
complications that might be associated with the
tongue piercing and advised to remove the ornament.
As there were no acute symptoms, no specic restora-
tive treatment was planned in agreement with the pa-
tient.
Case 3
A 20-year-old male patient presented at the dental
ofce on an emergency basis. Clinical examination
revealed an extra-oral mandibular swelling on the
right side. Intra-orally an acute abscess was diagnosed
Tongue piercing-related oral complications
Fig. 4. Clinical view of the crack in the distal wall, next to the
amalgam lling of tooth 27.
Fig. 5. Clinical view of the mandibular teeth. Teeth 37 and 47 are
characterized by a localised loss of tooth structure, especially on
the occlusolingual surface. Note the localisation of the piercing at
the level of teeth 37 and 47 when the tongue is in rest position.
235
Fig. 6. Panoramic radiograph showing evidence of localised abra-
sion of teeth 37 and 47.
Fig. 7. Model of the mandibular teeth giving evidence of the local-
ised abrasion of teeth 37 and 47.
Fig. 8. Clinical view of the front teeth showing loss of tooth struc-
ture of teeth 21 and 11 (both central incisors with a longitudinal
enamel crack and tooth 11 with extensive loss of enamel).
perimandibular on the rst molar. The patient had
great difculty opening the mouth. An apical radio-
lucency around the roots of the rst molar was seen
radiographically (Fig. 9). The tooth had previously
been restored with an occlusal amalgam lling. A
fracture line towards the mesial ridge and additional
loss of mesiolingual tooth substance were observed.
De Moor et al.
Fig. 9. Detail of the panoramic radiograph showing the coronal loss
of tooth structure and the apical radiolucency extending towards
the canalis mandibularis.
There was a small carious lesion in the distal surface.
The tooth was tender to palpation and percussion and
showed some mobility. The patient had been told to
see his dentist every six months, and until then had
never experienced problems with the respective tooth.
The emergency treatment consisted of a buccal in-
cision. There was no possibility of draining the ab-
scess through the pulp chamber. Antibiotics were pre-
scribed. A curettage around the root resulted in ex-
posure of pus. From the rst interview it was
ascertained that the patient had a tongue piercing for
over two years and a lip piercing for not longer than
one year.
Two days later the patient attended emergency
care again with severe edema extending to the neck.
A new incision with drain was performed and an ap-
pointment was made for extraction of the 46. A trans-
plantation of the mandibular third molar into the
healed extraction wound was then planned.
Discussion
Although oral piercing is a less conventional practice,
lip and tongue piercings are gaining popularity. Some
consultations (including telephone calls) with tattoo
and body-piercing studios in Gent, Ostend, Antwerp
and Brussels gave evidence of the increasing popu-
larity of this practice. The oral ndings in our 15 pa-
tients conrmed the ndings of previous studies and
case reports (19).
Most of the oral jewelry used comes in the form of
barbells with studs, labrettes with one stud, or hoops
(19). The tongue piercing is carried out in the
middle, just anterior to the lingual fraenum. The pro-
cedure is usually performed without any form of anal-
gesia, making the perforation in the protruding
tongue using a needle bearing equal gauge to that of
the barbell system, after which a temporary device is
inserted. A 3- to 5-week healing period is respected,
236
whereafter, the permanent ornament is placed. It is
then worn constantly to avoid the perforation site
closing spontaneously.
Many of those with oral piercings, also have
jewelry inserted in other parts of the body. While the
reasons for piercing are varied, it is generally con-
sidered either a form of body art, fashionable, a per-
sonal statement or daring (5). On the other hand,
body piercing is quite often seen as deviant behaviour
by society (4), which might explain why individuals
do not always present on their dental appointments
with the piercing in place. Piercings should therefore
be included in a list of differential diagnosis for any
inamed areas of soft tissue as they may not always
be readily obvious (11).
There are potential risks and adverse consequences
associated with any surgical-type procedure, and oral
piercing is by no means devoid of such hazards (10).
The body piercings are often carried out in tattoo
studios. Despite performing invasive procedures,
many body piercers do not have any formal education
on sterilization, effective skin care and proper infec-
tion control. Though, they are aware of the need for
infection control, particularly with respect to blood-
borne viral infections (1). They usually wear dispos-
able gloves and use sterile instruments and autoclaved
jewellery. The literature does not provide statistics on
the risk of the transmission of hepatitis, HIV, tetanus,
syphilis and tuberculosis due to the lack of regulation
of body piercing (4).
The most common complications reported by pa-
tients are those of pain or swelling. More severe reac-
tions are edema of the tongue and prolonged bleeding
if the blood vessels are punctured during the piercing
procedure. At this stage great care should be taken to
prevent lingual infections and edema, which can be
pronounced, widespread, and a hazard to the airway.
One case of a Ludwigs angina, secondary to recent
tongue piercing, has been reported (8).
Other complications related to the oral cavity have
been reported, including chipped and fractured teeth
during function, mucosal and gingival injury from the
metal barbells, increased salivary ow, calculus build-
up on the lingual surface of the ornament, and inter-
ference with speech, mastication and swallowing.
Although patients denied having speech difculties,
they admitted having them during the rst week of
healing. No further problems of this kind were ob-
served afterwards.
Chipping of teeth was registered in 12 of the 15
cases. Cusp fractures occur frequently in teeth with
extensive caries or large restorations which do not
protect undermined cusps (12). Apparently the pres-
ence of a foreign object interfering with the occlusion
may enhance these fractures. The occurrence of a
split tooth and a cracked tooth in association with a
tongue piercing has not yet been described. In this
Tongue piercing-related oral complications
respect, this article may serve to illustrate the most
immediate outcomes associated with intraoral pierc-
ing. Hence, with the growing popularity of oral pierc-
ing, individuals with tongue piercings should be made
aware of the risks of accidental biting or inadvertent
traumatic contact with teeth. The latter may result in
the fracturing of dental hard tissue (with or without
pulpal involvement) or, in the worst of cases, a crack-
ed or split tooth, which results in the inevitable loss
of the tooth.
Apart from damage to the natural dentition,
tongue piercings pose similar risks to large operative
procedures and xed prostheses containing porcelain.
In the patient group there was only one patient with
porcelain crowns. These were placed on the six upper
front teeth. A chipping of the porcelain at the gingival
lingual margins was registered, especially on the four
incisors. This was not due to tooth contact because of
the presence of an open bite.
One person complained of galvanic current during
contact between the stainless steel appliance and an
extensive amalgam lling. As the patient did not want
to remove his ornament, the amalgam was replaced
by a composite lling, which resulted in the dissol-
ution of the pulpal sensitivity.
237
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