Oral and Perioral Piercing

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1The Journal of Contemporary Dental Practice, Volume 1, No. 3, Summer Issue, 2000

Abstract

A comprehensive review of oral and perioral piercing is presented. This contemporary phenomenon hasmany implications for the piercee and for the oral healthcare professional. Oral and perioral piercing,which has become prevalent recently, has historical antecedents. The implications of piercing aredescribed in detail including sites at the tongue, lips, cheeks, frenum, and uvula. Complications occur-ring immediately after, soon after, and long after the piercing are detailed with special emphasis on thepossible deleterious effects on hard and soft oral tissues. Suggestions are provided for patient educa-tion including a pamphlet for downloading. Appropriate jewelry selection is described accompanied witha video clip demonstrating removal of jewelry during the dental appointment and a suggested technique

for keeping the piercing hole patent while the jewelry is out. Reviewing this information should educateand prepare the oral healthcare professional for the patient presenting with an oral or perioral piercing.

Keywords: Oral piercing, perioral piercing, labrette, piercing, jewelry

Oral and Perioral Piercing: A Unique Form of Self-Expression

Volume 1 Number 3 Summer Issue, 2000




Global SignificanceHistorically, the Mayans pierced the tongue todemonstrate virility and courage. The Eskimosand Aleuts pierced the lips of female infants aspart of a purification ritual and the lower lip of theboys as part of the passage into puberty. Thematerials used were stones, bones, or ivory.Overall, there has been a decrease in many of

these cultural practices with the introduction ofChristian influences.3

Still today, in some Third World areas, for reasonsof “religious, sexual, tribal or marital significance”oral piercings utilizing ivory, wood, pottery, ormetal in the mouth are customs that continue tobe practiced.4 As an example, the Surma tribe ofEthiopia wear large plates on their lower lips.5

The married men and widowers of the Suya tribeof Brazil adorn the lower lip with painted wooddisks.6 The parallels to current day piercing prac-tices are readily apparent (Fig. 1). Other tribeswear plugs on the upper lip or rings in the lowerlip. Some peoples in Southern India pierce thetongue with a skewer to maintain a vow ofsilence. Ritualistic piercings can be temporaryand may last only hours.3

In the current Western culture, the decision topierce is often a personal statement representingfashion, risk, and daring. There usually is no for-mal religious, tribal, or ornamental purpose.However, some piercings such as tongue, genital,and nipple sites, are used for the purpose of

increased sexual stimulation.

IntroductionPiercing of the tongue and perioral regions havebecome an increasingly popular form of body art.Tattooing is another common type of body adorn-ment, but the less permanent nature of piercinghas more appeal to today’s individuals seeking tomake personal statements. Oral and perioralpiercing has become so prevalent that it is highlylikely it is currently or soon will be seen in mostdental settings. Therefore, it is imperative oralhealthcare professionals are familiar with the phe-nomenon of oral piercing and well aware of thepossible sequelae. Oral/perioral piercing sites for

jewelry placement include the (1) tongue, (2) lips,(3) cheeks, (4) frenum, and (5) uvula.1 In fact, theAmerican Dental Association has formulated aposition statement opposing oral piercing.2



Types of Oral PiercingsThere are several types of oral piercings, howev-er, piercing the tongue is the most common prac-tice. There are two types of tongue piercing; themore common and safer dorsoventral and thedorsolateral. In dorsoventral piercing the jewelryis inserted from the dorsal to the ventral surfacesof the tongue (Fig. 2). This piercing is commonly

located in the middle of the tongue and majorblood vessels must be avoided during the proce-dure. Some individuals may choose to have mul-tiple dorsoventral piercings (Fig. 3).

Barbells are the most popular form of jewelryplaced in the dorsoventral piercing. Tongue ringscan also be utilized as jewelry for the tongue

when the piercing site is located near the tip orlateral borders of the tongue (Fig. 4).

The dorsolateral piercing is not a safe proceduredue to the vascularity of the tongue; therefore,dorsolateral piercing is not usually performed byprofessional piercers. In the dorsolateral piercing,both spheres of the jewelry are on the dorsum ofthe tongue at the lateral borders and locatedabout halfway in an anteroposterior direction.

The barbell is placed dorsally, curves downtoward the ventral side of the tongue, and resur-faces at the dorsal aspect.

Another popular oral piercing is the labrette whichrefers to piercing sites of the lip. (Fig. 5) Onetype is placed above the labiomental groove andcentered underneath the vermillion border. Thispiercing site is reminiscent of the lip piercing ofthe Suya tribe of Brazil and peoples of Africa.4,6

The jewelry at this location can contribute to gingi-

val recession at the anterior facial surface of themandibular region, due to physical trauma to thetissues.


Figure 2: Dorsoventral placement of barbell in tongue

Figure 3: Multiple dorsoventral piercings

Figure 4: Ring in tongue

Figure 5: Labrette



Lip piercings can be placed anywhere around thevermilion border. The most common site is theside of the lower lip near the commissure. Thepiercing goes through the lip extraorally andinserts into the oral cavity. A ring often is wornencircling the edge of the lip (Fig. 6).

Other less common oral/perioral piercing locationsare the cheeks, lingual frenum, and the uvula.Cheek piercings are known as ‘dimples’ since thebilateral placement corresponds to usual locationsof dimples (Fig. 7). The intraoral placement of theball of the jewelry at the buccal mucosa can leadto gingival recession and/or abrasion or chippingof the dentition. The lingual frenum location canbe referred to as a ‘web’ piercing. The uvula isnot a common piercing site because there are

inherent difficulties in performing the piercing andplacing the jewelry. Functional issues involvingthe gag reflex, throat irritation, and deglutitioncannot be overlooked. For individuals with sever-al oral piercings the effects on speech, mastica-tion, and deglutition are compounded.

ComplicationsComplications resulting from an oral piercing canoccur not only during the initial procedure, but atanytime thereafter. It is important for oral health-care professionals to be aware of these sequelaein order to inform both potential and currentpiercees and so that complications can be recog-nized during the oral examination. These effects

can happen during the piercing, shortly after, orlong after the piercing procedure.7,8,9,10,11,12

Complications During Piercing

Hemorrhage

The highly vascularized tongue, served by thedeep lingual artery and vein, will bleed duringthe procedure. This bleeding should soon bewell controlled. Extreme hemorrhaging canoccur and should receive immediate attention.

Nerve Damage

Being highly innervated by the Trigeminal(mandibular division), Facial, Hypoglossal andGlossopharyngeal nerves, it is possible to punc-ture a nerve during the procedure. This is morecommon with the dorsolateral than thedorsoventral tongue piercing, but can happenwith either. If nerve damage occurs, there canbe sensory (taste) or motor effects dependingon the nerves affected.

HIV, Hepatitis, Tetanus, and Other

Communicable Diseases

Any of these conditions can result from improp-er sterilization/disinfection ofequipment or supplies. Universal precautionsmust be utilized throughout theprocedure since blood and bodily fluids areinvolved in piercings.


Figure 6: Ring in lip

Figure 7: Piercing of the cheek



Complications Immediately Following Piercing

Local Inflammation of the TongueA swollen tongue can affect speech, mastica-tion, and deglutition.10 The submental and /orsubmandibular lymph nodes may becomeenlarged and tender. These effects can last upto three to five weeks. The mouth may be treat-

ed with a sea salt (saline) soak or rinse toreduce swelling. Persistent symptoms shouldreceive attention.

Localized InfectionInfection can largely be prevented with meticu-lous aftercare. Should infection occur,chlorhexidine rinses or systemic antibiotics, andlocal debridement can hasten healing. Anyinfection which does not respond in 1-2 daysshould receive professional attention since suchinfections can quickly become life threatening.

Trauma to Lingual GingivaErythema and edema of the gingiva is causedby the tendency to ‘play’ with the tongue ball byrubbing it against lingual gingiva. This canoccur from placement of the dorsal ball againstthe maxillary lingual tissue or the ventral ballagainst the mandibular lingual tissues.

Bacteremia

A systemic infection can result from bacteriaintroduced during piercing or can spread from alocalized infection that can occur anytime. A

healthcare provider should be consulted ifsymptoms occur such as fever, chills, shaking,or a red streaked appearance near the piercingsite.

Ludwig’s Angina

This condition involves an inflammation of con-nective tissue. It spreads rapidly to involve sub-mandibular, submental, and sublingual spaces.Signs would be painful tongue swelling, difficultyswallowing and speaking, and compromised air-way. This is a serious development thatdemands immediate professional intervention.

A compromised airway could prove fatal.11

Long-Term Complications

Tissue HyperplasiaTissue overgrowth can occur at the site andmay be accompanied by pain and edema. Thetissue can be excised, the wound treated, irri-gated, and then followed with re-insertion of asterile barbell. The tissues can repeatedly

become hyperplastic after excision.

Dehiscence (Fig. 8)

The ball of the labrette or lip barbell rubbingagainst the mandibular anterior facial gingivacan create a dehiscence over time. This couldoccur at any location where metal continuallyabrades against soft tissues. A periodontal con-sultation is advisable if this condition occurs.

Cracked /Fractured Teeth (Fig. 9)Damage to teeth can result from parafunctionaloral habits related to biting the barbell, careless

jewelry insertion, or during eating. Damage toteeth is most likely to occur after swelling hasdiminished and the barbell fits loosely within thetongue. Maxillary or mandibular teeth can sus-tain chipping from the ventral or the dorsal ball


Figure 8: Dehiscence of facial surface of teeth Nos. 24, 25

Figure 9: Fractured cusp of tooth No. 13



6The Journal of Contemporary Dental Practice, Volume 1, No. 2, Winter Issue, 2000

on the tongue.8,9 Symptoms include sensitivity tocold and sweets and pain upon biting pressure.The dental clinician who has administered amandibular block injection should be aware thatwhile the patient is still anesthetized, jewelry in thenumbed tongue can readily result incracked/chipped teeth during loss of tongue control.

Gingival Recession/Tooth Abrasion (Fig. 10)The tendency to repeatedly press the tonguebarbell against the mandibular lingual gingivacan lead to slight, moderate, or severe reces-sion of soft tissues. Labrette or lip piercingscan cause recession of the mandibular facialtissue.8 Similarly, the dentition can be abradedby the jewelry. Cosmetic or functional correc-tion can be implemented by a dentist.

Aspiration or IngestionA metal bar connects two balls of the barbell.One side of the rod has threads for screwing theball into position; this side is placed on the dor-sum. If the ball becomes loosened, there is apotential for swallowing or aspirating it.Additionally, during removal or reinsertion, the ballcould inadvertently slip down the throat.Aspiration or inhalation of jewelry parts couldoccur at anytime after a piercing.

Selection of JewelryAn important aspect of body piercing is selecting

proper jewelry, which is usually sold at the pierc-ing studio. This jewelry should be made of inertnon-toxic metal substances such as 14k or 18kgold, surgical stainless steel, titanium, or niobium.While the body piercing procedure may cost from

$15 to $50, the purchase of body jewelry is anadditional cost that can range from $35 to $100.Some individuals do not anticipate the cost of jew-elry when considering a piercing. Since proper

jewelry for the procedure may be seen as a frivo-lous extra cost, the adolescent may decide toplace costume jewelry or a safety pin in the open-ing instead. However, there is no substitute for

quality jewelry, since silver plating and finishes oncostume jewelry wear off quickly, leaving abrasivebrass that predisposes the pierced sites to infec-tions and allergic responses.

Patient Education

It is important for oral healthcare professionals toinform and educate prospective and newpiercees. This includes advising on safety andhealth issues as well as obtaining and maintainingoptimal oral hygiene during and after the proce-dure. An excellent brochure for patients has beenproduced by the Association of ProfessionalPiercers and a copy can be downloaded from theAssociation’s web site at:http://www.safepiercing.com /

If a patient or a concerned parent requests adviceabout tongue piercing, these points should beemphasized:

• Need for maturity/responsibility of the pierceesince there is ‘upkeep’ with the piercing site.

• Careful evaluation of the piercing establishmentfocusing upon sterilization and infection controlas well as issues and credentials of the piercer.

• During the initial 3-4 week healing period thetongue is swollen which affects speaking andeating.

• The possibility of infection always exists, as wellas fractured teeth and gum recession, whichmay require professional intervention.

• Quality jewelry of the appropriate size is a must.

Figure 10: Gingival Recession of facial surface of tooth No. 25



Management of the Dental Patient

Usually a patient presenting with an oral piercingwill not require any special considerations by theoral healthcare professional during treatment.However, when jewelry removal is indicated awell-prepared dental team should have the neces-sary supplies available in the office. This is

important because when oral piercing jewelry isremoved, closure may begin to occur in a shorttime.

During exposure of radiographs, it is often neces-sary to remove jewelry. For panoramic radi-ographs, all jewelry should be removed above theneck. Cheek and labrette jewelry should beremoved for periapicals and bitewing radiographsbecause of their location in relation to film place-ment and tube head.

The need for jewelry removal during local anes-thesia is at the discretion of the oral healthcareprofessional. The mandibular block is one injec-tion for which jewelry removal may be prudent.When the tongue is anesthetized, there isincreased possibility for tooth damage until theanesthesia has completely disappeared.

A well-prepared office will have temporary non-metal replacements for oral jewelry that isremoved for treatment. Hole closure is highlyvariable among individuals and in case the patientis not prepared, it is recommended that the oral

healthcare professional provide a replacement tokeep the piercing site patent.

One simple and inexpensive method is to providenylon line used in lawn care equipment, such as aweed eater, as a suitable choice for a non-metalreplacement. This material is available in differentdiameters. The equivalent of 12-14 gauge fortongue piercings and 14 gauge for other oralpiercings is comparable in size to the jewelry nor-mally used. The following steps can be

used to prepare the line

Cut the line to 1 1/2” lengths (Fig. 11)

Melt one end by fire, i.e., lighter or match (Fig. 12)

While warm, gently press this end against a flatsurface. The resulting end will be widened andflattened and serve as a ‘stop’. (Fig. 13)


Panoramic radiograph of a patient with tongue jewelry pressed againstthe maxillary anterior teeth and a pierced earring in the left ear.

Figure 11: Cutting nylon line

Figure 12: Melting one end of nylon line

Figure 13: Creating the “stop” end



With a pocketknife or scaler, smooth the roughend of the other side, narrowing the edge formore comfortable insertion. (Fig. 14)Package separately and autoclave individually.

The patient or the clinician should unscrew andremove the jewelry (Fig. 15, 16).

Quickly insert the nylon line (Fig. 17, 18).

For the tongue piercing, the flattened end of theline ‘stop’ would rest on the dorsum of the tongue(Fig. 19).

For the cheek, labrette, or lip piercings, insert theline from the mucosal side, leaving the flattenedend intraorally. After the dental procedure, thenylon line is removed and the jewelry re-inserted

into the piercing site (Fig. 20).


Figure 14: Smoothing the rough end

Figure 15: Unscrewing

Figure 16: Removing tongue jewelry

Figure 17: Insertion of nylon line

Figure 18: Insertion of nylon line

Figure 19: “Stop” end at dorsum

Figure 20: Re-insertion of jewelry



ConclusionToday’s oral healthcare professionals are likely tosee patients with, or considering oral/perioralpiercing sites. Educating and advising these per-spective or current piercees about the oral andsystemic ramifications of this practice can be ahelpful service. When jewelry removal is indicat-

ed prior to a dental procedure, it is important forthe oral healthcare professional to be familiar withthis process. Staying current with societal trendsthat affect the oral cavity will contribute towardcomprehensive care for those served.


References

1. Armstrong ML. You pierced what? Pediatr Nurs 1996;22(3): 236-238.2. American Dental Association, Current Policies, Prevention and Health Education, Policy Statement

on Intraoral/perioral Piercing, Chicago, American Dental Association, 1998:743.3. Ring ME. Dentistry: An illustrated history. Harry N. Abrams, Inc., ed. New York;1984.4. Fisher A. Africa adorned. W. Collins, ed. London; 1984.5. Beckwith C, Fisher A. The eloquent Surma of Ethiopia. National Geographic Magazine 1991;179(2):

77-91.6. Schultz H. Brazil’s big-lipped Indians. National Geographic Magazine 1962;121(1): 119-125.7. Price SS, Lewis MW. Body piercing involving oral sites. J Am Dent Assoc 1997;128(7): 1017-1020.8. Boardman R, Smith RA. Dental implications of oral piercing. CDA J 1997;25(3): 201-207.

9. Diangelis AJ. The lingual barbell: A new etiology for the cracked-tooth syndrome. J Am Dent Assoc1997;128: 1438-1439.

10. Fehrenbach MJ. Tongue piercing and potential oral complications. J Den Hyg 1998;72(1): 23-25.11. Perkins CS, Meisner J, Harrison JM. A complication of tongue piercing. Br Dent J 1997;182(4): 147-148.12. Maibaum WW, Margherita VA. Tongue piercing: a concern for the dentist. Gen Dent 1997 Sep-

Oct;45(5): 495-497.



About the Authors

Acknowledgements

The authors are grateful for the contribution of photographs made by John McDowell, DDS, MS, and byNorman Stoller, DMD, at the University of Colorado Health Sciences Center School of Dentistry and toMs. Julianne Gerbig for her initial involvement with this project.


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Oral and Perioral Piercing