Oral Piercing, Tattooing: RDHs Can Help Inform Patients about Body Modifications

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Self-expression comes in many forms, including body modifications such as tattoos and piercings. Intraoral or perioral piercings and tattoos are more popular than ever. The awareness of how these changes may affect oral health, however, is minimal. Dental hygienists can help answer patient questions concerning oral modifications, provide information about associated risks, and educate on after-care for the best possible outcomes.

Anthropologists consider body modifications to be a way for an individual to identify with a group, denote financial status, marital status, or beautify the body.  Piercing and tattooing have tribal origins that pre-date ancient Mayan civilizations and continue into modern-day cultures worldwide.2,6,11

Intraoral and Perioral Piercing

Intraoral piercing is a piercing in which both ends of the oral jewelry reside in the oral cavity. In contrast, perioral piercings have one end in the oral cavity while the other end penetrates the skin surface of the cheek, lips, or chin.11

The oral jewelry commonly used are studs, barbells, rings, and hoops made from stainless steel, gold, titanium, various alloys, or synthetic materials. Most plastic or acrylic jewelry harbor too much bacteria and are not recommended for routine wear.5,7,11

There are several types of intraoral and perioral piercing, but the tongue is the most common location. A dorsoventral tongue piercing is placed vertically from the ventral to the dorsal surface of the tongue with a barbell connecting a sphere on each end. This avoids major blood vessels and is safer than dorsolateral tongue piercing, which involves two puncture sites and is not generally recommended by piercers.15

Other types of intraoral and perioral piercings:

  • Labret: Located on the lower lip just above the labio-mental crease.
  • Madonna or Monroe: Upper lip, off-center (resembles a beauty mark). The name depends on the piercing location on the left or right side.
  • Medusa: A piercing on the philtrum of the upper lip centered just below the nose.
  • Smiley: A piercing of the maxillary labial frenum.
  • Frowny: A piercing of the mandibular labial frenum.19
  • Uvula: Rarely done, considered high risk for piercing, jewelry placement, aspiration, throat irritation, and interference with swallowing.15

These piercings may lead to oral and systemic complications. One systematic review found gingival recession in up to 50% of those with lip piercings, 44% with tongue piercings, and 26% had damage to teeth from a tongue piercing.2,11 Gingival recession was higher in those with lip piercings due to the jewelry’s location and constant friction against gingival tissue. Dental hygienists should be informed of the other possible complications that may arise during and after piercing procedures. Complications from oral piercings can be grouped into four categories:

  1. Complications that may happen at any time: Development or transmission of hepatitis B, C, D, E, tetanus, herpes simplex, HIV/AIDS, candidiasis, cellulitis, or infection at the piercing site. Allergic reactions, aspiration, or choking on jewelry, and interference with speaking, chewing, or swallowing.4,13,15,19
  2. Complications during the piercing procedure: Loss of consciousness, bruising, tenderness, swelling, and bleeding.19
  3. Primary postoperative complications: Nerve damage, prolonged bleeding, excessive salivation, impaired or metallic taste, gingival inflammation, or dentinal hypersensitivity.7,11,12,15
  4. Secondary postoperative complications: Keloid formation, scarring, pulpal sensitivity from galvanic currents, and gingival recession or overgrowth. Tooth abrasion, formation of a diastema or misaligned teeth, mobility, fracture, and tooth loss may occur. Chronic poor oral hygiene, in combination with porous jewelry or heavy smoking, may cause a shift in bacteria contributing to the development of periodontal disease.1,3,5,6,8,9,20

Dental Considerations for Intraoral and Perioral Piercings

Each U.S. state has varying requirements for informed consent, but most are specific to minors. In a study of 387 subjects, 60.4% stated they were not informed of risks involved with their piercing.2 Oral piercing takes an average of two to four months to heal. Patients should be instructed to only handle jewelry with clean hands and watch for signs of infection such as yellow or green discharge, thickening or dark tissue at the piercing site, and increasing redness, pain, or swelling.5,19

Perioral and intraoral jewelry may need to be removed before certain radiographs. If a patient has a new piercing, they should be rescheduled since the unhealed piercing is essentially an open wound.

The health of an oral piercing is reliant on good oral hygiene. Dental hygienists might recommend a soft toothbrush specifically for the piercing site in addition to an alcohol-free rinse daily. All forms of intraoral and perioral piercings should be removed before physical activities.5,11

Cosmetic and Intraoral Tattooing

A 2015 poll showed that 29% of Americans had at least one tattoo on their body. A cosmetic tattoo is extraoral and involves lining the vermillion border of the lips for a fuller appearance. Intraoral tattoos may be located on the inner labial mucosa, gingiva, or hard palate.10

Tattooing lip liner one to two shades darker makes the lips appear fuller. This procedure takes about 10 days of dry, chapped lips to heal. It generally lasts about 12 to 18 months.14

Intraoral tattoos are among the most painful sites to have tattooed. Inner lip tattoos are a popular trend since they are easily hidden and nonpermanent. The tattoo ink is unable to penetrate the mucosal membrane and susceptible to quicker cell turnover.14,17 These tattoos rarely last more than five years without a regular touch-up.16

There are currently no additional courses or training required of a tattooist to perform intraoral or cosmetic tattoos. The FDA has not approved any pigments for injection into the skin for cosmetic purposes, and pigments found in tattoo inks can be repurposed from the textile, plastics, or car paint industries.10,14,17

Dental Considerations for Cosmetic and Intraoral Tattooing

Patients should know that a nonalcoholic antibacterial mouth rinse will be needed several times a day for three to four weeks following an intraoral tattoo. No food or drink is allowed for several hours after the tattoo is done, and foods high in acid may cause irritation for some time.14,16 Again, good oral hygiene habits are very important to the health of all oral tissues.

Dermatologist Dr. Julia Carroll warns that there is a high risk of infection with intraoral tattoos, and that risk increases with each touch-up. Allergic reactions to tattoo ink may cause plaque ulceration, ulcero-necrotic, or excess hyperkeratotic reactions.14,18 The FDA has had reports of bad reactions to tattoo ink immediately after the tattoo and also years later.10

A Dental Hygienist’s Role

Dental hygienists should have some knowledge about the process of piercing and tattooing involving the oral cavity. Approach the subject without judgment but stress the importance of oral hygiene pre- and post-procedure. Encourage patients to research the establishment they plan to visit and stress the importance of only using a licensed professional they can follow up with in the event of any complications.

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