Oral Piercing

KEY POINTS

• Oral piercing of the tongue, lip, cheek, or other soft tissues is a form of body art and self-expression. Oral piercings are more typically seen in adolescents and young adults, and the tongue is considered the most common site for oral-piercing placement.
• Complications associated with oral piercing include: swelling, bleeding, infection, chipped or damaged teeth, gingival recession, lacerations/scarring, embedded oral jewelry (requiring surgical removal), airway obstruction, hypersalivation, palatal erythema, keloid formation, and purulent or unusual or discharge from the pierced region.
• Tongue splitting is a less common form of body modification within the oral cavity. By definition, the tongue-splitting process is one in which an individual’s tongue is severed into two pieces using various techniques. The procedure is inherently invasive and dangerous, with significant risks of severe bleeding, infection, inflammation, lingual nerve damage or other complications.
• The ADA advises against the practices of cosmetic intraoral/perioral piercing and tongue splitting, and views these as invasive procedures with negative health sequelae that outweigh any potential benefit.

BACKGROUND

Oral piercing is an ancient practice of body modification and self-expression that is also common in modern society.^{1, 2} Oral piercings may be placed intraorally (most commonly on the tongue) or periorally on the lips, cheeks or a combination of sites.^3-5 Oral piercings are more typically seen in adolescents and young adults, and the tongue is considered the most common site for oral-piercing placement.¹ There are two primary forms of oral piercing: the term intraoral piercing describes a piercing in which both ends of the oral jewelry (device or apparatus) reside in the oral cavity, as seen with tongue piercings. Similarly, the term perioral piercing describes a piercing in which one end resides in the oral cavity and the other end penetrates the skin surface in the perioral region (e.g., the cheek, upper or lower lip, chin or associated tissues).

Common forms of oral jewelry include studs, barbells, rings and hoops, which are fabricated using a variety of metals, such as stainless steel, gold, titanium and various alloys or synthetic materials.

While some individuals may consider oral piercings to be popular or trendy, numerous studies and case reports have shown that oral piercings can lead to a wide range of oral and systemic complications, including chipped teeth, gingival recession, embedding or aspiration of jewelry and other potentially severe infections, such as Ludwig’s angina⁶ or infective endocarditis.⁷

Tongue splitting is another, less common, form of body modification that literally splits, or bifurcates, an individual’s tongue from front to back, creating a “forked” appearance down the anterior midline. Tongue splitting is an invasive and dangerous procedure that directly compromises the intact physical barrier of the tongue surface, rendering it susceptible to severe bleeding and pain, bacterial infection, lingual nerve damage and other adverse effects.⁸

COMPLICATIONS OF ORAL PIERCING

As with any puncture wound or incision, oral piercings can cause pain,^{5, 9, 10} swelling,^{4, 5, 9-11} and infection.^{9, 10, 12} Other complications of intraoral and perioral piercings include increased salivary flow;^{10, 13}gingival injury or recession;^{2, 9, 11, 14, 15} damage to teeth, restorations or fixed prostheses;^{2-4, 10, 11, 15, 16} lingual abscess;¹⁷ interference with speech, mastication or deglutition;^{3, 5, 9} scar tissue and keloid formation;^{13, 18} and allergic contact dermatitis.^{19, 20} Because of the tongue’s vascular nature, prolonged bleeding can result if vessels are punctured during the piercing procedure.²¹ Purulent, unusual and/or colored discharges from oral piercings have also been reported.²²

The technique for inserting tongue jewelry may abrade or fracture anterior dentition,^{3, 4, 10, 16} and digital manipulation of the jewelry can significantly increase the potential for infection.^{9, 11, 12} Airway obstruction due to pronounced edema⁴ or aspiration of jewelry poses another risk, and aspirated or ingested jewelry could present a hazard to respiratory or digestive organs.^{5, 11} Oral jewelry can compromise dental diagnosis by obscuring anatomy and defects in radiographs. There are also reports of the jewelry becoming embedded in surrounding oral tissues, requiring surgical removal.^{2, 11, 23} Studies have also shown that lip or tongue piercings can harbor periodontopathogenic bacteria,^{24, 25} and that piercing jewelry made of synthetic materials (e.g., polytetrafluoroethylene or polypropylene), rather than steel or titanium, have lower levels of bacterial colonization.²⁶

Oral piercing complications are relatively common. According to one systematic review, gingival recessions were identified in up to 50% of individuals with lip piercing and in 44% of those with tongue piercing; tooth damage was also seen in 26% of individuals with tongue piercings.²⁷ Complications can arise either during the oral-piercing procedure, immediately after its completion, or over the long term (after initial placement).²

Several case reports in the published literature have described severe or life-threatening complications related to oral piercing.^{6, 28} In one case, a 25-year-old British woman developed Ludwig’s angina, a rapidly spreading cellulitis involving the submandibular, sublingual and submental fascial spaces bilaterally, four days after receiving a tongue piercing.⁶ Intubation was necessary to secure the woman’s airway, and when antibiotic therapy failed to resolve the condition, surgical intervention was required to remove the barbell-shaped jewelry and decompress the swelling in the floor of the mouth.

RISKS ASSOCIATED WITH TONGUE SPLITTING

Like oral piercing, tongue splitting is an invasive, albeit uncommon, procedure with inherent risks of severe bleeding, pain, infection and nerve damage.⁸ Reports describing the morbidity and mortality associated with tongue splitting are relatively sparse in the research literature, but the risk of complications secondary to surgical procedures (including pain, swelling and infection) is well known.

As a matter of ADA policy, the Association advises against the practices of oral piercing and tongue splitting. The latter practice may be performed using a variety of techniques, which are typically provided in a non-sterile setting (e.g., body-piercing parlor or similar establishment). The practice of tongue splitting entails the deliberate alteration of an individual’s tongue for nonmedical purposes, often without the presence of health professionals and without standard infection control practices, proper sterilization or the provision of safe, appropriate after-care.²⁹ The tongue’s anatomic location, high vascularity and proximity to diverse oral microflora and biofilms present significant potential risks for viral infection or transmission of pathogenic organisms.

DENTAL CONSIDERATIONS FOR PATIENTS WITH ORAL PIERCING

In the U.S., dentists commonly encounter and treat patients, particularly younger adults, with various forms of oral piercing or oral jewelry (e.g., studs, rings, hoops, barbells) in the intraoral/perioral region. Piercings of the tongue and other oral sites are associated with increased risk of orodental trauma, gingival recession and potentially traumatic lacerations.⁵ Pierced individuals are also at increased risk of infection due to vast number of bacterial species in the oral cavity.

Individuals who receive oral piercings can expect pain and swelling within the first few days after the procedure.² Use of an alcohol-free mouthrinse is advised for use after oral piercing to cleanse the mouth and site of the oral piercing.³⁰ After the swelling subsides, the piercee will need to visit their piercer after the piercing procedure to replace the original, longer piece of jewelry with a shorter piece, which should help minimize damage or irritation to oral tissues.³¹

To reduce risks of oral infection after piercing procedures, pierced individuals should be advised to maintain a standard oral hygiene regimen that includes: twice-daily tooth-brushing using fluoride-containing toothpaste and a soft-bristle toothbrush; regular use of floss or another interdental cleaner; and use of alcohol-free mouthrinse during and after the healing period.³⁰

Dental patients with an oral piercing or split tongue should be advised to keep their piercing site clean, avoid playing with oral-piercing jewelry and monitor their oral cavity for signs of infection, including swelling, pain, tenderness or unusual discharges (particularly those with an offensive odor).^{30, 32}  All forms of intraoral or perioral jewelry (e.g., tongue barbell, lip ring or stud, etc.) should be removed before participating in athletic and other physical activities, particularly contact and collision sports.³³

• References
• ADA Resources
• Additional Resources

Prepared by: Center for Scientific Information, ADA Science Institute
Reviewed by: Scientific Information Subcommittee, ADA Council on Scientific Affairs
Last Updated: September 18, 2017

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