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Oral and facial piercing: Associated complications and clinical repercussion Maria Jose Garcia-Pola, MD, BDS, MPDH, PhD1/ Jose Manuel Garcia-Martin, MD, DDS, PhD1/ Pedro Varela-Centelles, DDS, MMedSci, MPDH, PhD2/ Angel Bilbao-Alonso, MD, PhD2/ Rocio Cerero-Lapiedra, MD, DDS, PhD1/ Juan Seoane, MD, DDS, MPDH, PhD2

Objectives: To investigate the complications of oral and facial piercing and its frequency in an extensive series of cases. Method and Materials: A sample of 2,266 consecutive patients requiring dental care over a period of 1 year was included in this cross-sectional observational study. A total of 83 piercing wearers were identified. Demographics, piercing site, clinical complications, adverse effects of piercing, motivation, and setting of piercing were determined through an interview and intraoral examination. Results: The 18- to 27-year age bracket showed a significantly higher prevalence of piercing wearers (mean years of wear 2.9 ± 3.8). Esthetic reasons were the most frequent stimulus for piercing insertion (86.7%). Up to an 80.8% of the devices were inserted in a tattooing studio. Forty-nine patients (59.0%) reported postoperative or late piercing complications. Postoperative pain (40.9%; 95% CI = 29.7 to 52.1) was significantly more frequent than infection (10.8%; 95% CI = 3.5 to 18.1) or postpiercing bleeding (7.2%; 95% CI = 1.0 to 13.4). When oral locations were compared to facial sites, the former had caused significantly more problems (␹2 = 10.1; P = .001), pain (OR = 0.96; 95% CI = 0.08 to 0.97) and swelling (OR = 0.20; 95% CI = 0.06 to 0.68) being the most frequent undesirable effects associated with oral piercing. Conclusions: Complications associated with oral and facial piercing are frequent, and many of them might well be avoided if effective legal and hygienic measures were adopted. Educational interventions targeted to the population between 18 and 27 years of age are advisable, particularly when dealing with oral piercing. (Quintessence Int 2008;39:51–59)

Key words: adverse effects, , complications, epidemiology, facial, oral

Exotic decorative and ritual practices involv- of body art in Western societies.2 However, ing body piercing, scarification, and tattooing no exact data for these practices are avail- have been practiced in some societies for able, and estimated prevalences have been years.1 Nowadays, piercing in different obtained from short case series of body regions of the head is an emerging practice piercing with heterogeneous samples and that has gained popularity as an expression different inclusion criteria.2,3 Piercing is generally an unregulated prac- tice occurring in a multitude of diverse settings and is usually performed by unli- 1Medical and Surgical Specialties, School of Medicine, University censed individuals.2 Reports of adverse of Oviedo, Oviedo, Spain. effects and complications associated with 2Stomatology Department, University of Santiago de piercing in the head area are growing and Compostela, Santiago de Compostela, Spain. include a wide range of banal problems4–7 Correspondence: Dr M. J. García-Pola, Medical and Surgical and severe infections (eg, tetanus,8–10 endo- Specialties, School of Medicine, University of Oviedo, Campus 11,12 13 del Cristo B, Julián Clavería s/n, 33006 Oviedo, Spain. Fax: 34 98 carditis, cerebral abscess, Ludwig angi- 5252305. E-mail: [email protected] na,14–16 glomerulonephritis,17,18 toxic shock

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syndrome,17 extensive bleeding, and even air- Statistical analysis way obstruction19). However, only sporadic Statistical analysis was performed using the descriptions and unreliable estimates (with SPSS 13 (SPSS) and Epidat 3.1 (Direccion very divergent rates) of the complications are Xeral de Saude Pública) statistical packages. available for the number of persons who The descriptive analysis for quantitative vari- have experienced problems related to body ables considered the mean as a centraliza- piercing.20 Therefore, the aim of this study tion parameter for the distribution and the was to investigate the complications of oral standard deviation as a spread measure. For and facial piercing and its frequency in an qualitative variables, relative frequencies and extensive series of cases. confidence intervals were selected. Com- parisons between proportions were under- taken by means of the Pearson chi square or Fisher exact tests. The nonparametric Mann- METHOD AND MATERIALS Whitney U was employed for comparison of the means. The odds ratio (OR) and its confi- Ethical considerations dence interval (CI) were used as a measure All patients were informed about the aims of for associations between sites and piercing the study and about the fact that their volun- complications. All tests considered 2 tails and tary enrollment would not affect in any way a significance level of 5%. the quality or extent of care provided at the Health Centre. An informed consent form was signed by each patient before entering the study. RESULTS

Study design A total of 96 oral or facial piercings were A cross-sectional study was performed on a found in the 83 patients (43.4% males, sample of 2,266 consecutive patients requir- 56.6% females) identified from the original ing dental care at the Oral Health Service of sample of 2,266 consecutive patients (preva- the Vallobin Health Centre in Oviedo, Spain, lence 3.6%). The 18- to 27-year age bracket between March 2005 and March 2006. Oral showed a significantly higher prevalence of and facial piercing was defined as “the pen- piercing wearers than the other age groups etration of jewelry into openings made in (Table 1). The mean age of the patients with such oral and facial areas as eyebrows, ears, piercing was 25.1 ± 7.7, and they had been lips, tongue and nose,”21,22 including the ear- wearing the device for a mean of 2.9 ± 3.8 lobe in men.23 As a result of this criterion, years. The identified sites were ear (n = 51), and after clinical exploration and a struc- nose (n = 20), eyebrow (n = 7), lower lip (n = tured interview, 83 piercing wearers were 15), and tongue (n = 3). No jewelry was found identified. in the uvula, cheeks, or upper lip. Esthetics was the most frequently men- Variables tioned stimulus for piercing (86.7%), followed The variables considered were demographics by sexual motivations (7.2%) and “seeking a (age, sex, years of piercing wear), piercing site transgressor look” (6.0%). Up to 80.8% of the (oral and facial locations), and clinical compli- devices were inserted in a tattooing studio, cations experienced (pain, swelling, infection, 9.6% were installed in pharmacies, another postpiercing bleeding, contact allergies, or any 4.8% were placed in jewelry stores, and the other complication). Patients with piercing in final 4.8% were inserted at the wearer’s oral sites were also investigated for dental frac- home by a friend. tures, dental hypersensitivity, masticatory inter- Forty-nine patients (59.0%) reported post- ferences, gingival recession, dysgeusia, or operative or late piercing complications, the hypersalivation. All patients were also asked most frequent being pain (n = 34), swelling (n about their motivations for piercing and the = 20), infection (n = 9), and postoperative type of setting in which it was installed. bleeding (n = 6), with significant differences in

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Table 1 Age and gender distribution of oral or facial piercing wearers

Males Females Piercing wearers

Age group Total n With piercing Total n With piercing % 95% CI

< 18 199 5 213 5 2.4 0.8–4.0 18–27 91 12 128 33 20.5 14.9–26.1 28–37 113 14 183 9 7.7 4.5–10.9 38–47 190 3 69 0 1.1 0.2–3.3 48–57 132 1 168 0 0.3 0.0–1.8 > 58 344 1 436 0 0.1 0.0–0.7 Total 1,069 36 1,197 47 3.6 2.8–4.4

Table 2 Demographic features and frequency of complications according to facial piercing site

Ear (n = 51) Nose (n = 20) Eyebrow (n = 7)

Complications % 95% CI % 95% CI % 95% CI

Age 25.9 ± 8.9 24.1 ± 5.8 26.2 ± 4.3 Gender (male) 56.8 42.2–71.4 5.0 0.1–24.8 57.1 18.4–90.1 Years of wear 3.5 ± 4.6 1.8 ± 1.5 4.0 ± 3.9 Pain 33.3 19.4–47.2 40.0 19.1–63.9 57.1 18.4–90.1 Swelling 19.6 7.7–31.4 10.0 1.2–31.6 57.1 18.4–90.1 Postpiercing bleeding 9.8 3.2–21.4 5.0 0.1–24.8 28.5 3.6–70.9 Infection 15.6 4.7–26.6 5.0 0.1–24.8 0.0 0–40.9

their rate of occurrence (␹2 = 35.3; P = .000). DISCUSSION Postoperative pain (40.9%; 95% CI = 29.7 to 52.1) was significantly more frequent than Strengths of the study infection (10.8%; 95% CI = 3.5 to 18.1) or post- Reports on piercing prevalence in the gener- piercing bleeding (7.2%; 95% CI = 1.0 to 13.4). al population are scarce. There is a single Five of 18 oral-piercing patients (27.7%) European study, undertaken in Germany, revealed buccal gingival recession related to a where a representative survey of 2,043 lower lip piercing (OR = 0.27; 95% CI = 1.9 to patients revealed a prevalence of 6.8%.24 7.0); 3 patients (16.6%) reported increased Body piercing seems to be more popular in salivation; and 1 patient (5.3%) showed a tooth Australia (8%),25 particularly among universi- fracture caused by the device. ty students, with prevalences rising up to No significant differences in terms of com- 32%26 or even to 51%.23 However, no previ- plications could be identified among the dif- ous studies have assessed both the frequen- ferent facial sites (P > .05) (Table 2). However, cy and features of oral and facial piercing when oral locations were compared with complications and adverse effects in the facial sites, the former had significantly more general population. Moreover, the informa- problems (␹2 = 10.1; P = .001), pain (OR = tion about the variables considered in this 0.96; 95% CI = 0.08 to 0.97) and swelling study was collected by clinical examination (OR = 0.20; 95% CI = 0.06 to 0.68) being the and structured clinical interview, whereas most frequent undesirable effects associated previous studies on piercing prevalence col- with oral piercing. lected data mostly via questionnaires.

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Limitations of the study Many governments neither license nor The method for selecting patients included certify persons who perform body piercing.29 in this study (nonrandom, consecutive Although some operators show great con- patients) should be kept in mind when gen- cern for safety, infection control, and individ- eralization of the results is considered. ual selectivity of suite and device, many are However, the demographic features of the “huckster[s], who, after attending a single patients studied do not significantly differ piercing seminar, set up a ‘studio’ with the from the population of reference. On the hope of making a fast buck.”29 other hand, several variables could have In the present series, only 9.6% of the been affected by some memory bias, which devices were inserted in a health care setting. may have reduced the frequency of the This circumstance has undoubtedly favored reported complications; taking into account the growing number of complications—mainly the low mean value of the “years of wear” pain, infection, swelling, and bleeding—arising variable, however, this bias does not seem to from these practices.3 The overall incidence be relevant. of medical complications of body piercing ranges from 9.2%23 to 70%.28 Complications Key findings and comparison of oral and facial piercing have a wide scope with other studies of severity and are reported from time to time The present results, obtained from a sample in the scientific literature as case reports of care-seeking patients, are on par with (Tables 3 and 4) or as case series.3 Most of those of previous reports with a prevalence the interviewed piercing wearers (59%) in this of oral and facial piercing of 3.6%, which series reported some kind of complication. As reaches a significantly higher 20.5% for the with previous reports,3,105 continuous postop- 18- to 27-year age bracket. erative pain has been the most common The overall prevalence of body piercing undesired consequence in this series. Local varies widely from 6.8% to 51.0%.27 This infection is recognized in the literature as a divergence probably reflects methodological complication occurring in 10% to 20% of differences with heterogeneous samples cases,4 usually caused by Staphylococcus in terms of age, inclusion criteria, or data aureus, group A Streptococcus, or Pseudo- collection (questionnaires or interview). The monas species.4,106 The treatment of these present study does not consider pierced infections includes removal of the device and earlobes for women,23 as ear piercing has topical antibiotics (mupirocin ointment, fusidic traditional roots in Western societies (an esti- acid, or clortetraciclin). When dealing with mated 80% of American women have deep infections (abscess and fasciitis), surgi- pierced ears5), and thus it does not reflect the cal debridement and systemic antibiotics concept of piercing as a term aimed at become necessary. describing practices that do not have a long- No statistically significant differences in established background in the society where terms of frequency of complications among the investigation is undertaken.27 different facial sites could be identified, as Earlobes and ear cartilage are the most with previous reports describing that pierc- commonly pierced sites. Other frequent areas ing through the cartilage appears to cause include nose, lips, eyebrows, and tongue. As no increase in the general complication rate happens with other reports, no jewelry was when compared with piercing through soft found in cheeks, frenulum, or uvula.3 tissues,32 but oral piercing seems to cause The reasons behind the practice of pierc- more inflammation and pain than facial pierc- ing are diverse and include self-expression, ing. During the first hours after piercing inser- personal need, declaration of independence tion, the tissues surrounding the wound start and individuality, a wish to fit into a group, the inflammatory process and cause pain. and a desire to enhance body image and This process progresses for the next 3 or 4 sensuality.26–28 However, the most frequently days and continues for several weeks.25,96,107 mentioned motive for piercing both in the lit- The rate of complications resulting from erature and in this series is esthetics.2 head and neck piercing is determined by the

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Table 3 Complications of piercing in the facial region

Facial region Complication Agent Suggested treatment

Eyebrow Chronic granulomatous Antibiotics and surgical removal lesions30 Ear Chondritis14,31 Pseudomonas aeruginosa Ciprofloxacin Perichondritis32,33 Lactobacillus (DM) Ciprofloxacin, I&D and abscess34–36 Staphylococcus aureus Streptococcus pyogenes Local infection4–7 Staphylococcus species 2% Mupirocin ointment, first-generation Streptococcus species cephalosporins, penicillinase-resistant penicillins, I&D Post-streptococcus Group A streptococcus Eradicate infection; supporting therapy glomerulonephritis17,18 -hemolytic streptococcus Hepatitis37–45 HVB, C, D Clinical control, specific treatment: interferon Tetanus8–10 Clostridium tetani Wound treatment, antibiotics, vital support Device embedded Surgical removal in the lobe46–48 Keloid formation49–54 Surgical excision, intralesional corticosteroid injection, cryosurgery, pressure dressing, radiation, laser therapy Lymphadenopathy55 Treatment of the underlying disease Pseudolymphoma56 Clinical control, corticosteroids Sarcoidal tissue reaction57 Corticosteroids Torn ear lobe50,58,59 Surgical correction Systemic infection7,60,61 -hemolytic streptococcus Guided antibiotic therapy (hemoculture Endotoxin of S aureus and antibiogram) Erysipelas9 Penicillin Endocarditis and Antibiotic therapy ventricular septal defect62 Tuberculosis63 Specific antituberculosis treatment Contact dermatitis64–69 Avoid the causing metal; topical corticosteroids Nose Postpiercing infections70 S aureus Cloxacillin Endocarditis11,12 S aureus Antibiotic therapy -hemolytic streptococcus Granulomatous P aeruginosa Mupirocin, fluocinolone acetonide perichondritis of the Staphylococcus species nasal ala71,72 Device embedded72 Surgical removal

(DM) Diabetes mellitus; (I&D) incision and drainage; (HVB, C, D) Hepatitis B, C, and D virus

materials employed, the experience of the mandibular incisors in up to 20% or 80% of practitioner, hygiene, and after care.3 The site the cases described in the literature3,76,109; of insertion (oral versus facial) also seems to only one case could be found in this series, be of importance. however. A number of adverse effects and site-spe- An increase in saliva production has been cific complications associated with oral pierc- reported for 20% of oral piercing wearers.3,26 ing have been published: is Gingival recession has also been described often confined to the midline and anterior to in oral piercing wearers74–77; in the present the lingual frenum,108 which causes compli- sample, this association was significantly cations such as tooth fracture, fissures, abra- associated with lip piercing. sion, or enamel chipping in molars and

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Table 4 Complications of piercing in the oral region

Oral region Complication Agent Treatment

Lips Local infection73 S aureus Cloxacillin, chlorhexidine Gingival recession74–78 Surgical correction Foreign body reaction79 Device removal Tongue Teeth abrasion, teeth Tooth restoration fractures80–87 Endocarditis88–90 Haemophilus aphrophilus, Antibiotic treatment Neisseria mucosa Local infection91,92 S aureus, Ciprofloxacin Pseudomonas species Postpiercing edema, trauma NSAIDS, periodontal maintenance to the lingual anterior gingiva93 Deep abscess of the tongue Antibiotics, maintenance of airway and acute dyspnea with permeability hereditary angioedema94 Cerebral abscess (cerebellum)13 St viridans Antibiotics, possibly surgery Ludwig angina with infection Group A streptococcus Maintain airway; systemic antibiotic; of the spacies14–16 surgical drainage Piercing partially embedded Surgical removal within the tongue95,96 Hypotensive collapse following Vital support measures extensive bleeding19 Upper airway compromise93 Airway permeability Tetanus97 C tetani Wound treatment, antibiotics, vital support measures Periodontal bone loss Periodontal treatment, piercing removal and pocketing98 Tongue swelling and pain92,99-102 Symptomatic treatment (NSAIDS) Device or parts of it 6-24 h follow-up, endoscopic extraction swallowed73,80,103 Gingival recession87,100 Device removal, periodontal treatment Papular lesion on tongue83 Excisional biopsy Difficulties in mastication, Piercing removal swallowing, and speech81,82,101 Galvanic currents80 Removal of piercing and metallic dental restorations Sarcoid-like foreign body Follow-up, corticosteroid therapy reaction104

(NSAIDs) Nonsteroidal anti-inflammatory drugs.

Clinical applicability of the study (tooth fracture, gingival recession, and hyper- As reports on adverse effects and complica- salivation) complications associated with oral tions associated with oral and facial piercing and facial piercing are frequent. Many of are increasing, dental clinicians should be these problems might well be avoided if aware of body-modification trends and proce- effective legal and hygienic measures were dures3 and should be prepared not only to adopted. Educational interventions targeted address complications of head and neck pierc- to the population between 18 and 27 years of ing but also to provide information to patients.20 age are particularly advisable, particularly It is concluded that local (pain, swelling, when dealing with oral piercing. infection, and bleeding) and site-specific

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