Karolina Kaczor1, Anna Zawadzka1, *Piotr Rożniatowski2, Emil Korporowicz2, Dorota Olczak-Kowalczyk2
Complications of piercing in the oral cavity – a review
Powikłania piercingu w obrębie jamy ustnej – przegląd piśmiennictwa
1Students’ Research Circle, Department of Paediatric Dentistry, Medical University of Warsaw
2Department of Paediatric Dentistry, Medical University of Warsaw
Head of Department: Professor Dorota Olczak-Kowalczyk, MD, PhD
Piercing jest coraz częściej spotykaną formą ozdabiania ciała zarówno wśród młodzieży, jak i młodych dorosłych. Jednym z miejsc, w których spotyka się różnego rodzaju kolczyki, jest jama ustna, szczególnie język i wargi. Z uwagi na to, lekarze dentyści powinni potrafić diagnozować i leczyć ewentualne powikłania, które często jako pierwsi rozpoznają. Powikłania można podzielić na: wczesne pozabiegowe, takie jak: obrzęk, ból, przedłużone krwawienie, oraz przewlekłe, gdzie wyróżniamy: recesje dziąsłowe, uszkodzenia tkanek zębów i nawracające infekcje w okolicy kolczyka. Istnieją także doniesienia o powikłaniach ogólnoustrojowych wymagających hospitalizacji, zagrażających życiu, jak infekcyjne zapalenie wsierdzia po zabiegu piercingu czy obrzęk języka prowadzący do duszności. Większość zabiegów kolczykowania jest przeprowadzana w studiach piercingu, w warunkach braku kontroli sterylizacji, co dodatkowo zwiększa ryzyko wystąpienia powikłań. Celem pracy było przedstawienie aktualnej wiedzy na temat powikłań użytkowania piercingu w obrębie jamy ustnej. Lekarz dentysta mogący mieć kontakt z pacjentami z biżuterią nazębną powinien potrafić rozpoznawać i leczyć powikłania, udzielać wskazań higienicznych, a także pomóc podjąć świadomą decyzję pacjentom planującym wykonanie piercingu w obrębie jamy ustnej.
Piercing is a form of body art increasingly popular among teenagers and young adults nowadays. Oral cavity, especially tongue and lips, is where piercing is placed. Because of that, dentists should be able to diagnose and treat possible complications, which they can see as the first person. There are early (acute) complications, like swelling, pain, prolonged bleeding, and chronic complications, such as dental recession, tooth damage and recurring infections around the piercing. There are reports about systemic complications when hospitalization is needed, life-threatening like infective endocarditis after piercing treatment or tongue swelling with following airway compromise. Most of piercings are placed in piercing studio with no sterilization control what can increase complications possibility. The aim of this study was to present the actual knowledge about complications of using oral piercing. Dentists who can treat patients with oral piercing, should know how to diagnose, treat piercing complications and help maintaining good oral hygiene. They also should know how to help patients who plan oral piercing procedures to make an informed decision.
Modification in human body appearance has not been initiated in the contemporary world. It was a practice present as early as in antiquity in various cultures giving voice to the previous customs and traditions (1). One of the forms of body art is oral cavity piercing and the application of tooth jewellery which has recently become more and more widespread among teenagers and young adults in developing countries. Great interest in piercing is related to the prevailing fashion and aesthetic reasons (2, 3), the willingness of young people to belong to a group or express themselves, yet there are also sexual motives specified and confrontation (4, 5).
Owing to the growing number of young patients with piercing in the oral cavity, a dentist should be able to provide the patient with professional information as well as be prepared to find and treat common piercing complications (6). The goal of the work is to present state-of-the-art as regards piercing and jewellery within the oral cavity on the basis of a review of available references, with particular attention paid to early and late piercing complications.
General information concerning piercing
Piercing within the oral cavity is present among women more often than men, who – on the other hand – more often have several rings. In the majority of cases these are habitual smokers (1, 5-8). Patients usually find no motive at all for the selection of piercing location, specifying their decision to be a whim, unpredictable decision (4). On the basis of multiple studies, it may be stated that most often rings are placed in the tongue, usually in the median sulcus, and later in lips; the remaining locations one can find jewellery in are the frenula, cheeks and the uvula (5-7, 9, 10).
The most common type of rings are barbell (a bar ended with a ball on both sides), the second most common being labret (a bar with a ball on one side and flat on the other). Ring-type rings are most common within the lips (open circle with a ball on one or both the ends) (7). Ziebolz et al. report that the most common rings among teenagers include ball-shaped and cone-shaped rings made of titanium, stainless steel or acrylic (2, 6). What is important is that jewellery may be made of other metals, such as nickel, or may contain their admixtures (7). It has been proven that the society has a negative opinion as regards pierced people. Concerned about stereotypical perception by the dentist, patients would often take out the rings when they have an appointment, which makes it more difficult for the dentist to combine the symptoms present in the oral cavity and the patient using piercing (5). It is suggested that a survey for patients reporting to the dentist should contain questions concerning the presence of piercing in the oral cavity taking into account the period of time the jewellery being discussed has been used for (11).
Piercing is considered an invasive method of body decoration. It requires interrupting the continuity of the skin and mucous membranes, which gives way for pathogenic germs to easily enter the body. Owing to the anatomy of the head and the neck, the infections started may rapidly and aggressively permeate to adjoining areas leading to some dangerous complications (12).
Oral cavity piercing complications concerning both the mucous membrane and the tissues of the teeth have been divided into early (acute) and late (chronic) (13).
In almost all the patients, following piercing in the oral cavity, there are early complications observable after less than 24 hours since the procedure (7, 14). This group includes pain, oedema, bleeding and local infections. Owing to its anatomy and abundant vascularisation, the tongue is particularly susceptible to the occurrence of complications, also life-threatening ones (9, 12). Following tongue piercing procedure, there is a high probability of lingual pain and oedema, which leads to problems eating, speaking (15) and swallowing (3, 14). On the other hand, in the case of a procedure within the lips there is oedema, bleeding and mild infections (6). In the study of López-Jornet et al., pain following the procedure was determined by the patients to be on average 4 in the 0-10 VAS (Visual Analogue Scale). The complaint most often persisted up to one week following the procedure. Rare symptoms include increased saliva outflow (3, 4, 8, 16), irritation and contact allergic reactions within the cutaneous layer of the lip, especially when the ring is made of nickle (7-9) or it has some admixture of palladium (17), metallic taste in the mouth (4, 18). Early complications usually subside of their own, on average after approx. 2 weeks (7), although some research show that the period of healing amounted to approx. 4 weeks in the case of tongue piercing and 5 weeks for the lip (16).
There has been a retrospective analysis carried out in the USA concerning pierced patients reporting to the Emergency Unit in the period 2002-2008, the majority of cases was caused by infections (frequently applied to the tongue) in the vicinity of the rings, local wounds (comparably the tongue and lip) and mechanical traumas in the area of the ring. 91% of the traumas (out of n = 24 459) took place within the first 30 days following ring location and the majority of visits took place in the first week following the procedure. The most serious cases were episodes of life-threatening dyspnoea in patients following tongue piercing, caused by infections or inflammation and oedema of the tongue, 300 patients (1%) required inpatient stay after such an incident (19).
Out of the reports concerning piercing-related complications threatening the life of a patient, one should pay attention to: prolonged post-procedure bleeding, herpes virus infection, hepatitis B, hepatitis C, HIV (15), problems breathing caused by increased oedema of the tongue or ring aspiration to the respiratory tract (14), tongue tissue necrosis, tongue abscess, tetanus infection (20), facial paralysis and infectious endocarditis (7, 9, 12). In the period of 1985-2007 there were at least 22 cases described of infectious endocarditis following piercing, out of which 7 applied to the tongue and 1 to the lip (21), which were caused by Streptococcus viridans (22), Neisseria mucosa (23), Haemophilus aphrophilus (24), Staphylococcus aureus (25). Literature also shows the case of a 25-year-old patient in whom – 4 days following the insertion of a tongue ring – tongue and floor of the mouth pain and oedema were observed, persisting after antibiotics therapy administered (amoxicillin 500 mg 3/days after the procedure). Dysphagia was observed, pyrexia and both sided oedema of the submental and submandibular areas, inside the mouth there was an advancing necrosis of the tissues of the floor of the mouth. Ludwig’s angina was diagnosed, in such a case inpatient treatment was necessary as well as intubation, surgical excision of necrotic tissues and the ring, drainage application and antibiotics therapy (26).
The next potential complications following ring insertion may occur within the next few weeks. Lesions created in the oral cavity caused by a foreign body manifest themselves as articulation disorders, problems swallowing, chewing, the creation of galvanic current between the ring and the metal fillings (7). The type of the reported ailments by the patients changes as early as after the first week of piercing. The most common ones include problems with wound healing, breaking the teeth, dental plaque and calculus deposition on the ring and extension of the ring hole (14).
The observed chronic complications include the prevailing recurring infections within the area of piercing and damage to dental hard tissue. There can also be gingival recession observed in the vicinity of the ring, most often described in accordance with Miller’s classification (27). A risk factor for the recession may be the frequently recurring gingival infections among piercing users (6).
Leichter and Monteith examined 91 people with labret type ring placed in the middle of the lower lip. In the case of all the examined, jewellery had contact with teeth 31, 41, at which gingival recession was observed in 68.13% of the cases. The frequency of the disorders described was 7.5 times higher as compared to the control group, with no piercing within the oral cavity. The authors drew conclusions that the longer the time of ring using, the greatest level of gingival recession observed (1).
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