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ABSTRACT

The case presented is designed to draw attention to the increasingly common occurrence of tooth frac- ture as a result of trauma incurred from a barbell inserted during . Oral piercing is on the rise. Of concern to health personnel are the associated risks, which include dam- age to dentition, infection, speech impediment and nerve damage. Also of concern is the belief that in some cases, clients considering may not be receiving sufficient care instructions, hence putting them at greater risk of post-operative complications. We conclude that a public health campaign in the form of health promotion and education is mandatory to ensure safe responsible piercing, and recommend that workshops, forums and educational leaflets aimed at the piercers, the clientele and the health care workers be developed in Alberta. MeSH Key Words: self-mutilation/complications; tongue/injuries; tooth fractures/etiology. © J Can Dent Assoc 1998; 64:803-5 This article has been peer reviewed.

Body Piercing and Society dental community is the recent vide sufficient health information lthough it has an ancient increase in intraoral piercing,4,5 to their clients. As a result of these history, body piercing has which is the insertion of jewelry findings, we present here a case of only recently attained pop- into soft oral tissues including the fracture and possible abrasion A 1 ularity in Western society.1,2 For , and tongue. It is criti- caused by a tongue in a 23- centuries, body piercing was part cal that the dental profession year-old Caucasian male. Al- of many cultures and religious become aware of the recent inter- though this case is not unique in rites.2 Ancient Egyptians pierced est in this type of body piercing, of its presentation, it serves to high- their navels to signify royalty, the impact this trend may have on light for the dental profession some of the risks involved in intra- Roman centurions wore nipple dentition and speech, and of the oral body piercing. rings as a sign of virility and health risks that are associated courage, and Mayans pierced their with piercing. Clinical Case 3 for spiritual purposes. In The literature on the effects of A 23-year-old single male pre- North America, body piercing was tongue piercing is limited. What sented himself to the University of 5 also a tradition of the Sioux. there is points to the risk of tooth Alberta undergraduate clinic com- Journal Today, popular sites for body damage, the possibility of aspira- plaining of “chipped molars and 4 December piercing include the , eye- tion of jewelry, speech modifica- some worn teeth.” The patient was 1998 brows, lips, nose, nipples, navel, tion,3 and an increased risk of a transient worker for an oil com- Vol. 64 penis, scrotum, labia, and infection.5 Furthermore, we sus- pany. Long hours on the job and No. 11 tongue.4,5 Of significance to the pect that body piercers do not pro- other personal factors induced a

Canadian Dental Association 803 Filename: botchway.qxd English B/W

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Because of pierced tongue was forced to aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab the fact that he was a smoker, his the tongue’s vascular nature, heal- remove his barbell because his aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab 3 aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab medical history was unremarkable. ing is generally quick, occurring speech was altered. aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab His past dental history had included within 4 to 6 weeks after the pierc- aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab 3. Aspiration: It is not unreason- aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab 7 extractions (third molars) and dental ing. The procedure is usually per- able to count as a risk the acci- hygiene. Current clinical findings formed without anesthesia. The dental aspiration of a piece of revealed no extraoral abnormali- protruding tongue is clamped and the jewelry inserted in the ties. The intraoral exam revealed no supported by a piece of cork, then tongue should the jewelry carious lesions and good periodon- pierced by a needle bearing equal come apart.4 tal health, with a periodontal gauge to that of the barbell stem.4 4. Infection and allergic response: screening record (PSR) of 2.6 The patient said he had his Infection from unsterilized However, a number of distinct tongue pierced simply because he instruments is always a risk. fractures involving enamel and “wanted to.” While the reasons for Body piercing is often done in dentin were observed on the piercing are varied, it is generally the same establishments as tat- incisal edges of teeth #12 and #31 considered either a form of body too studios.7,9 Despite perform- and the lingual surfaces of #36, art, fashionable, a “personal state- ing invasive procedures, many #46 and #16. 7 ment” or daring. Piercings are also body piercers do not have any The soft tissues were all within 7 sought for their sexual and spiri- formal education on steriliza- normal limits with the exception 4,8 tual benefits. Our patient also tion, effective skin care and of the anterior central area of ven- had his nipples pierced. Both his proper infection control.9 Con- tral aspect of the tongue, which piercings were hidden and he had sequently, piercing may include appeared slightly inflamed. The removed his tongue ring prior to an increased risk of the transmis- patient did not reveal the use of a presenting for the oral examina- sion of Hepatitis B, HIV/AIDS, ring until questioned about the tion. There is some suggestion that tetanus,6 syphilis and tuberculo- inflamed areas, at which time he body piercing is seen as deviant sis.5 The literature does not pro- inserted the barbell-type ring 5 behaviour by society, which may vide statistics on the risk of trans- (Fig. 1). explain why some individuals do mission of these diseases due to The patient also reported a not always present for their dental the lack of regulation on body tongue-thrusting habit with the appointments with their pierced piercing.5 Allergic reactions to additional parafunctional habits of ring in place. Piercing should nickel or other alloys used in the grinding and clenching. therefore be included in a list of dif- metals are also a possibility.7 All Upon questioning the patient as ferential diagnosis for any inflamed jewelry should be made of inert to the possible cause of the frac- areas of soft tissue as it may not non-toxic metals7 such as stain- tures, he indicated that he had always be readily obvious. less steel, 14K niobium or obtained the ring eight months - There are a number of risks .7 The patient reported lier and was having difficulty associated with the practice of that his barbell was made of becoming accustomed to the pres- intraoral body piercing that are of . ence of a foreign body in his oral concern to the dental community. 5. Other: A number of side effects cavity. The fractures had all They include: occurred within the first month of associated with piercings have 1. Tooth fracture: Our clinical 5 obtaining the barbell. He also indi- been documented, including case serves to illustrate one of cated some initial difficulty in pain, deep cyst formation, the most immediate outcomes speech and mastication following hypertrophic scarring, damage associated with intraoral pierc- the piercing. Despite the patient’s to deeper structures such as ing. In addition, when a patient parafunctional habits, he indicated superficial and nerves, reports parafunctional habits that he occasionally slept with the hematoma formation and neu- such as bruxism, it is not 5 ring inserted. We conclude that roma. Septicemia and toxic unreasonable to infer that the this only served to compound the shock syndrome have also risk of tooth fracture increases. risk of trauma to his dentition. been reported in cases of Individuals who choose pierc- severely infected body pierc- Risks of Intraoral Piercing ing need to be made aware of ings.4 It is not unreasonable to Piercing of the tongue is nor- this risk and that damage to the infer that other risks specific to mally performed in the midline of dentition may result in cracked the practice of tongue piercing the tongue anterior to lingual tooth syndrome or outright may include damaged frenum.4 Because of the swelling, fracture of the dental hard tis- tissue, permanent numbness Journal it is recommended that a longer sues with or without pulpal and loss of taste. barbell shank initially be placed in involvement. Many piercers are not profes- December 1998 the tongue, followed by the inser- 2. Speech impediment: A review sionals. It is suggested that in some Vol. 64 tion of a shorter barbell shank of the literature suggests that cases, post-operative instructions No. 11 after healing. (Significantly, the speech may be hindered.3 In are inadequate. Proper post- patient had not had the initial one case, a student with a operative instructions should

804 Canadian Dental Association aaaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbb aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab both health care professionals and aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab INFORMATION aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab the public be prepared and distrib- aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab uted as a public health education aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab PACKAGE aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab measure. This would enable us to aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab aaaaaaaaaaaaaaaaaaaaaaaaaaaaabbbbbbbbbbbbbbbbbbbbbbbbbbbbbab advise patients who may be LIBRARY/RESOURCE pierced as to the procedures they should follow and the risks they CENTRE may . It is also proposed that a survey be conducted to investigate PACKAGE SPECIAL!!! the practices of body piercers in Edmonton and the knowledge of their clients. ■ TWO FOR ONE SALE!!! The following is a list of Dr. Botchway is a clinical assis- CDA Resource Centre pack- tant professor, Oral Diagnosis, Oral Health Sciences, Faculty of ages that can be ordered by Medicine, University of Alberta. members for $2.50 each Fig. 1: Barbell rings … a risky option? Dr. Kuc is associate professor, (plus applicable taxes), Oral Diagnosis, Oral Health instead of the regular $5.00 Sciences, Faculty of Medicine, University of Alberta. price. Offer expires January include information on the care of 31, 1999. the pierced site; for tongue pierc- Reprint requests to: Dr. C. Botchway, Room 2089, Oral ing, that means frequently using a To place your order, contact Health Sciences, Faculty of mouth rinse and avoiding alcohol, Medicine, University of Alberta, the CDA Resource Centre, at: 7 spicy foods and smoking. Edmonton AB T6G 2N8. Tel.: 1-800-267-6354, ext. Learning More About Piercing 2223, or (613) 523-1770, ext. It is clear from the literature References 2223; Fax: (613) 523-6574; or that whether health professionals 1. Scully C, Chen M. Tongue pierc- E-mail: [email protected]. like it or not, body piercing will ing (oral body art). Br J Oral Maxillo- 9 continue. As a result, they need fac Surg 1994; 32:37-8. Air abrasion to know about the procedure to be 2. Boardman R, Smith RA. Dental able to provide helpful informa- Ceramic implications of oral piercing. Oral tion.2 Health professionals and the Health 1997; 87(10):23-31. Conscious sedation (this general public still have much to learn about the effects of tongue 3. Armstrong ML, Ekmark E, Brooks month’s package) B. Body piercing: promoting piercing on the integrity of denti- informed decision making. J Sch Evidence-based dentistry tion and speech, and the risk of Nurs 1995; 11:20-5. infection. It is also important that The dental team they understand the motivation 4. Reichl RB, Dailey JC. Intraoral body piercing: a case report. Gen and feeling of gratification that Dental focal infection Dent 1996; 44:346-7. compel people to choose body piercing in spite of these possible 5. Wright J. Modifying the body: The diabetic dental patient complications. Based on the liter- piercing and tattoos. Nurs Stand 1995; 10:27-30. Hepatitis B ature and the case presented, it is clear that damage from such 6. Rethman J, Rethman M. Peri- Implant-supported dental piercing should be of concern to odontal screening and recording. the dental profession. Why, when and how. Pract Hyg 1993; 2:19-23. Implant-supported dental Recommendations 7. Armstrong ML. You pierced what? As health care professionals, Pediatr Nurs 1996; 22:236-8. restorations we need to be aware of the proce- 8. Armstrong M.L. Body piercing: Odontogenic cysts dures and risks involved in tongue what practicing RNs should know. piercing, and of the social and Texas Nurs 70:8-10 1996. Partnerships and Journal psychological reasons that lead 9. Malloy D. Body piercings. In: associateships December people to engage in this practice Vale V, Juno A (eds). Research No. 1998 regardless of the risks. 12: Modern Primitives. San Fran- The smile Vol. 64 No. 11 Hence, it is proposed that cisco, Calif: Research Publications, leaflets addressing the issues for 1989. Tooth bleaching update

Canadian Dental Association 805