Oral Piercing/Jewelry

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.

Numerous studies and case reports have shown that oral piercings may lead to a wide range of oral and systemic complications, including chipped teeth, gingival recession, soft tissue or mucosal injuries, embedding or aspiration of jewelry and other potentially severe infections, such as Ludwig’s angina⁶ or infective endocarditis.^7-9

Tongue splitting is another 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.¹⁰

As with any puncture wound or incision, oral piercings may cause pain,^{5, 11, 12} swelling,^{4, 5, 11-13} and infection.^{11, 12, 14} Other complications of intraoral and perioral piercings may include increased salivary flow;^{12, 15} gingival injury or recession;^{2, 11, 13, 16, 17} damage to teeth, restorations or fixed prostheses;^{2-4, 12, 13, 17, 18} lingual abscess;¹⁹ interference with speech, mastication or deglutition;^{3, 5, 11} oral lichenoid lesions;²⁰ scar tissue and keloid formation;^{15, 21} and allergic contact dermatitis.^{22, 23} Because of the tongue’s vascular nature, prolonged bleeding may result if vessels are punctured during the piercing procedure.²⁴ Purulent, unusual and/or colored discharges from oral piercings have also been reported.²⁵

The technique for inserting tongue jewelry may abrade or fracture anterior dentition,^{3, 4, 12, 18} and digital manipulation of the jewelry may significantly increase the potential for infection.^{11, 13, 14} 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, 13} Oral jewelry or ornaments 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, 13, 26} Studies have also shown that lip or tongue piercings can harbor periodontopathogenic bacteria,^{27, 28} and that piercing jewelry made of synthetic materials (e.g., polytetrafluoroethylene or polypropylene), rather than steel or titanium, have lower levels of bacterial colonization.²⁹

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.³⁰ Complications may 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. 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. In another case report, a healthy 19-year-old woman contracted herpes simplex virus, presumably through a recent tongue piercing.³¹ The infection progressed to fulminant hepatitis and subsequent death.

Like oral piercing, tongue splitting is an invasive procedure with inherent risks of severe bleeding, pain, infection and nerve damage.¹⁰ 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. In a recent case report, a 29-year-old woman experienced multiple episodes of bleeding and worsening chest pain following a tongue-split procedure; she was subsequently diagnosed with acute pulmonary embolism (sudden blockage in a lung artery) three days after the procedure.³²

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, typically without the presence of health professionals and without standard infection control practices, proper sterilization or the provision of safe, appropriate after-care.³³ 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.

Forms of oral jewelry and tooth ornamentation have been used in various cultures worldwide, from ancient Mayan civilization³⁴ to modern-day Central America³⁵ and Southeast Asia.³⁶ Archeological studies have shown that Mayan peoples practiced dental ornamentation through placement of inlays (made of jade or other stones) and by embedding jewelry on anterior teeth.^{34, 35} Ancient Mayans also performed filing of teeth in angular shapes and other patterns as a rite of passage to adulthood.³⁴

In recent years, several types of oral jewelry have become used as contemporary forms of oral body art and self-expression, such as tooth gems (using diamonds or precious stones),^{37, 38} dental grills (also called “grillz” or “fronts”),^{39, 40} or ornamental gold crowns worn on anterior teeth (usually an incisor).^{35, 41} Dental grills (bejeweled removable devices typically made from gold or silver and placed on anterior teeth) were popularized in music videos during the 1980s, and their use has continued over time.⁴² Some celebrities have promoted dental grills through online social media, and other forms of oral decoration have also been publicized such as inner-lip tattoos⁴³ and tooth tattoos (decorated porcelain crowns with ink or color designs that are placed on the dentition).³⁸

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 tooth fracture, chipping or wear/abrasion, gingival recession and potentially traumatic lacerations.^{5, 8} Pierced individuals are also at increased risk of infection due to the vast number of bacterial species in the oral cavity.

Individuals who receive oral piercings can expect pain and swelling within the first five 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.⁴⁴ 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 will help minimize damage or irritation to oral tissues.⁴⁵

To help 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.⁴⁴

Previous research has shown that oral piercing objects (e.g., barbells) can serve as sites for observable plaque accumulation and higher concentrations of periodontopathogenic bacteria.²⁸ Similarly, there is considerable potential for plaque accumulation on tooth gems, dental grills and other oral jewelry, which can increase caries risk and periodontal infection over time (particularly when oral hygiene practices are insufficient). For these reasons, long-term wearing of oral jewelry is discouraged due to potential risks of adverse oral sequelae, including dental caries (due to entrapment of food particles/debris), enamel damage, chipped teeth, or periodontal inflammation.^{39, 46} Patients should exercise their best judgment when considering or pursuing such procedures to help reduce any risk of adverse events or deleterious outcomes (e.g., insufficient infection control and/or instrument sterilization).

Dental patients with an oral piercing or split tongue should 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 with an offensive odor.^{45, 47} 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.⁴⁸

POLICY STATEMENT ON INTRAORAL/PERIORAL PIERCING, TOOTH GEMS/JEWELRY AND TONGUE SPLITTING
(Trans.1998:743; 2000:481; 2004:309; 2012:469; 2016:300; 2021: XXX)

Resolved, that the American Dental Association advises against the practices of cosmetic intraoral/perioral piercing, tooth gems/jewelry and tongue splitting, due to the increased risk of negative health outcomes.

American Dental Association
Adopted 1998 (Revised 2021, 2016)

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JADA “For the Patient” page: The Piercing Truth About Tongue Splitting and Oral Jewelry (July 2012)

ADA MouthHealthy.org page:  Oral Piercings

American Academy of Pediatric Dentistry: Policy on Intraoral/Perioral Piercing and Oral Jewelry/Accessories (2021)

Massachusetts Department of Public Health: OMG … That Piercing Can Do What?

Mayo Clinic: Piercings: How to Prevent Complications

Online Continuing Education: Oral Piercings: Implications for Dental Professionals (offered by Crest/Oral-B)