Copyright C Munksgaard 2000

Endod Dent Traumatol 2000; 16: 232237

Printed in Denmark . All rights reserved

Endodontics &
Dental Traumatology
ISSN 0109-2502

Case report

Tongue piercing and associated oral and

dental complications
De Moor RJG, De Witte AMJC, De Bruyne MAA. Tongue
piercing and associated oral and dental complications. Endod Dent
Traumatol 2000; 16: 232237. C Munksgaard, 2000.
Abstract The insertion of metal objects into intraoral and perioral
sites is growing in popularity. However, there are numerous oral and
dental complications associated with tongue piercing. Fifteen patients with tongue piercings (pierced in the body of the tongue,
anterior to the lingual frenum) attending the dental office of the
authors, with and without complaints, were clinically and radiographically examined. The most common dental problem registered was chipping of teeth. Furthermore, two cracked teeth and
four teeth with cusp fractures were also seen. One case of selective
dental abrasion was registered. Trauma to the lingual anterior
gingiva was the most common gingival problem. A salivary flow
stimulating effect was only reported by 2 of the 15 individuals. None
of the patients complained of interference with speech, mastication
and swallowing. One case of galvanic currents produced by the appliance was registered. On the basis of the registered data, we concluded that patients need to be better informed of the potential complications associated with tongue and oral piercings, and that the
dental profession can serve this role.

Piercing has been a custom of many civilizations for

thousands of years. It is known that piercing the body
has spiritual, aesthetic and sexual connotations (1).
Only during the last decade has the art of body piercing attained popularity in Western society (1, 2). Of
significance to the dental profession is the recent increase in intraoral piercings (3, 4), which is the insertion of jewelry into soft oral tissues including the lips,
cheeks and tongue.
Tongue piercing is a form of oral body art that
presents a unique concern for the dental profession. A
review of medical and dental literature found limited
information regarding potential oral or dental complications. Moreover, the information is limited to the
findings in individual case reports. Among these findings are: the transmission of systemic infections, such
as hepatitis B, tetanus and HIV (47); a Ludwigs an232

R. J. G. De Moor,
A. M. J. C. De Witte,
M. A. A. De Bruyne
Department of Operative Dentistry and
Endodontology, School of Dentistry, University
Hospital, University of Gent, Gent, Belgium

Key words: dental trauma; tongue piercing

Roeland De Moor, Department of Operative
Dentistry and Endodontology, School of Dentistry,
University Hospital, University of Gent,
De Pintelaan 185,
B 9000 Gent, Belgium
Tel: 0032 9 240 40 00. Fax : 0032 9 240 38 51
Accepted January 21, 2000

gina secondary to tongue piercing (8); hemorrhage

with great concern in medically compromised patients (9); changes of speech, swallowing and mastication after placement of the ornament (3, 5, 6, 10);
aspiration of parts of the jewelry (3); allergy to the
metals when the piercing is not of the best quality or
when it contains metals such as nickel (3, 5); traumatic injury to the teeth leading to chipping, fracturing of teeth and restorations, and pulpal damage (3).
With the growing number of piercings (among
them also oral piercings) and being aware of the risks,
complications and dental implications asssociated
with such procedures, the oral situation in 15 patients
with tongue piercings is evaluated. A clinical screening of such a patient group has not yet been published
in the scientific literature. To support the observations, 3 particular cases are presented.

Tongue piercing-related oral complications

Table 1. Data on the oral implications of 15 tongue piercing cases
Complications/factors

No. of cases*

Cases requiring immediate professional medical and dental treatment as a result of the piercings
Cases resulting in a split tooth with acute symptoms i.e. pain
Cases resulting in a cracked tooth with acute symptoms i.e. pain
Cases resulting in cracks with loss of tooth substance (cusp fracture) with acute symptoms
Cases resulting in cracks with loss of tooth substance (cusp fracture) without acute symptoms
Cases resulting in chipping of teeth
Cases resulting in tooth abrasion
Cases with galvanic currents produced by the appliance
Cases developing infection
Cases resulting in gingival injury
Cases with noticably increased salivary flow
Range of frequency of jewelry removal

6
1
1
1
3
12
1
1
1
6
2
(never) 11
(once a day) 2
(twice a day) 2

* Average length of time pierced is 13.2 months.

Material and methods

The oral situation of 15 patients with tongue piercings

attending the dental office of the authors, with and
without acute symptoms, was clinically and radiographically evaluated. Thirteen patients had a piercing of the barbell-type (a bar with 2 balls) and 2 patients had a piercing of the labrette-type (a ball on the
ventral site of the tongue and a flat end on the dorsal
side of the tongue).
Objective features, such as visual damage to the
teeth, gingival injury, developing infection, noticably
increased salivary flow, and allergy to the metal, were
scored. The patients were also questioned about subjective symptoms, such as the impairment of speech,
swallowing and mastication.
Results

Table 1 illustrates the data regarding the oral implications of tongue piercing. The average length of time
pierced was 13.2 months. Of the 15 patients 4 were
seeking immediate dental care due to cracked teeth
(2) or the loss of tooth substance due to a crack (2).
One of the latter was in combination with an extensive and acute abcess of the right lower first molar.
The other patients consulted the dentist for a regular
control. In this group there was also one patient who
complained of sensitivity in an upper left first molar,
extensively restored with amalgam, each time there
was contact between the filling and the stud of the
barbell. Though they did not have any subjective
complaints, 3 other patients needed immediate dental
care to prevent further cracking of a tooth or further
loss of tooth substance.
Twelve of the cases indicated damage to the teeth
in the form of chipping and one in the form of extreme abrasion of the second molars. Six cases reported gingival injury. Only 2 patients developed no-

ticeably increased salivary flow. One patient reported

the development of an infection. Allergic reactions to
the metal were not seen. The frequency of jewelry
removal ranged from never to twice a day. The average time the jewelry was left out was 15 min, ranging
from 5 to 30 min. When the tongue piercing was removed it was cleansed in all instances with chlorhexidine and one patient placed the piercing daily in hot
boiling water for 15 min. One patient had once swallowed a part of the barbell.
Case report
Case 1

A 24-year-old man visited the dental office on an

emergency basis. His chief complaint was a mobile
upper left second molar which had become painful a
week earlier. Clinical and radiographical examination
revealed a mobile 27 with an occluso-distal amalgam
filling and a sinus tract mesial to the mesial root of
this tooth (Fig. 1). The tooth was percussion sensitive
but not temperature sensitive.

Fig. 1. Radiograph of the posterior teeth, with periradicular radiolucency around tooth 27.

233

De Moor et al.

Fig. 2. View on the mesial wall of the access cavity: the crack ends
in the pulp chamber floor.

It was decided to remove the amalgam filling and

to perform a root canal treatment. After removal of
the central part of the amalgam filling, a crack in the
mesial wall of the tooth ending in the pulp chamber
floor was seen (Fig. 2 and 3). It was therefore decided
to extract the tooth. After extraction of the tooth a
second distal crack ending in the furcation was also
seen (Fig. 4). On further information, it became clear
that the patient had been experiencing subjective
symptoms for more than one year, starting a few
weeks after the piercing with a moderate temperature
sensitivity and pain while biting.
Case 2

A 33-year-old male presented at the dental office for

a routine dental examination and professional oral
prophylaxis. During the intra-oral examination, a
pierced tongue was noted (Fig. 5). The piercing had
been performed more than one year earlier and there
had been no symptoms of infection.
The patient admitted to enjoying biting down on
the studs and frequently clacking, as loud as possible, the studs against the upper front teeth as a
234

Fig. 3. Clinical view of the crack in the mesial wall of tooth 27.

game with friends. He then expressed some concern

about the presence of some chipped teeth. He had
not been informed of the possible complications associated with tongue piercing.
An examination of his dentition revealed injury to
the second molars, which had considerable loss of
tooth substance (Fig. 6 and 7). The teeth showed a
selective abrasion of the coronal surface. Furthermore, the left central incisor showed a local loss of
substance at the incisal edge (Fig. 8), which was due
to selective biting on the bar of the barbell.
The patient was warned of the oral and dental
complications that might be associated with the
tongue piercing and advised to remove the ornament.
As there were no acute symptoms, no specific restorative treatment was planned in agreement with the patient.
Case 3

A 20-year-old male patient presented at the dental

office on an emergency basis. Clinical examination
revealed an extra-oral mandibular swelling on the
right side. Intra-orally an acute abscess was diagnosed

Tongue piercing-related oral complications

Fig. 6. Panoramic radiograph showing evidence of localised abrasion of teeth 37 and 47.

Fig. 7. Model of the mandibular teeth giving evidence of the localised abrasion of teeth 37 and 47.

Fig. 4. Clinical view of the crack in the distal wall, next to the
amalgam filling of tooth 27.

Fig. 8. Clinical view of the front teeth showing loss of tooth structure of teeth 21 and 11 (both central incisors with a longitudinal
enamel crack and tooth 11 with extensive loss of enamel).

Fig. 5. Clinical view of the mandibular teeth. Teeth 37 and 47 are

characterized by a localised loss of tooth structure, especially on
the occlusolingual surface. Note the localisation of the piercing at
the level of teeth 37 and 47 when the tongue is in rest position.

perimandibular on the first molar. The patient had

great difficulty opening the mouth. An apical radiolucency around the roots of the first molar was seen
radiographically (Fig. 9). The tooth had previously
been restored with an occlusal amalgam filling. A
fracture line towards the mesial ridge and additional
loss of mesiolingual tooth substance were observed.
235

De Moor et al.

Fig. 9. Detail of the panoramic radiograph showing the coronal loss

of tooth structure and the apical radiolucency extending towards
the canalis mandibularis.

There was a small carious lesion in the distal surface.

The tooth was tender to palpation and percussion and
showed some mobility. The patient had been told to
see his dentist every six months, and until then had
never experienced problems with the respective tooth.
The emergency treatment consisted of a buccal incision. There was no possibility of draining the abscess through the pulp chamber. Antibiotics were prescribed. A curettage around the root resulted in exposure of pus. From the first interview it was
ascertained that the patient had a tongue piercing for
over two years and a lip piercing for not longer than
one year.
Two days later the patient attended emergency
care again with severe edema extending to the neck.
A new incision with drain was performed and an appointment was made for extraction of the 46. A transplantation of the mandibular third molar into the
healed extraction wound was then planned.
Discussion

Although oral piercing is a less conventional practice,

lip and tongue piercings are gaining popularity. Some
consultations (including telephone calls) with tattoo
and body-piercing studios in Gent, Ostend, Antwerp
and Brussels gave evidence of the increasing popularity of this practice. The oral findings in our 15 patients confirmed the findings of previous studies and
case reports (19).
Most of the oral jewelry used comes in the form of
barbells with studs, labrettes with one stud, or hoops
(19). The tongue piercing is carried out in the
middle, just anterior to the lingual fraenum. The procedure is usually performed without any form of analgesia, making the perforation in the protruding
tongue using a needle bearing equal gauge to that of
the barbell system, after which a temporary device is
inserted. A 3- to 5-week healing period is respected,
236

whereafter, the permanent ornament is placed. It is

then worn constantly to avoid the perforation site
closing spontaneously.
Many of those with oral piercings, also have
jewelry inserted in other parts of the body. While the
reasons for piercing are varied, it is generally considered either a form of body art, fashionable, a personal statement or daring (5). On the other hand,
body piercing is quite often seen as deviant behaviour
by society (4), which might explain why individuals
do not always present on their dental appointments
with the piercing in place. Piercings should therefore
be included in a list of differential diagnosis for any
inflamed areas of soft tissue as they may not always
be readily obvious (11).
There are potential risks and adverse consequences
associated with any surgical-type procedure, and oral
piercing is by no means devoid of such hazards (10).
The body piercings are often carried out in tattoo
studios. Despite performing invasive procedures,
many body piercers do not have any formal education
on sterilization, effective skin care and proper infection control. Though, they are aware of the need for
infection control, particularly with respect to bloodborne viral infections (1). They usually wear disposable gloves and use sterile instruments and autoclaved
jewellery. The literature does not provide statistics on
the risk of the transmission of hepatitis, HIV, tetanus,
syphilis and tuberculosis due to the lack of regulation
of body piercing (4).
The most common complications reported by patients are those of pain or swelling. More severe reactions are edema of the tongue and prolonged bleeding
if the blood vessels are punctured during the piercing
procedure. At this stage great care should be taken to
prevent lingual infections and edema, which can be
pronounced, widespread, and a hazard to the airway.
One case of a Ludwigs angina, secondary to recent
tongue piercing, has been reported (8).
Other complications related to the oral cavity have
been reported, including chipped and fractured teeth
during function, mucosal and gingival injury from the
metal barbells, increased salivary flow, calculus buildup on the lingual surface of the ornament, and interference with speech, mastication and swallowing.
Although patients denied having speech difficulties,
they admitted having them during the first week of
healing. No further problems of this kind were observed afterwards.
Chipping of teeth was registered in 12 of the 15
cases. Cusp fractures occur frequently in teeth with
extensive caries or large restorations which do not
protect undermined cusps (12). Apparently the presence of a foreign object interfering with the occlusion
may enhance these fractures. The occurrence of a
split tooth and a cracked tooth in association with a
tongue piercing has not yet been described. In this

Tongue piercing-related oral complications

respect, this article may serve to illustrate the most

immediate outcomes associated with intraoral piercing. Hence, with the growing popularity of oral piercing, individuals with tongue piercings should be made
aware of the risks of accidental biting or inadvertent
traumatic contact with teeth. The latter may result in
the fracturing of dental hard tissue (with or without
pulpal involvement) or, in the worst of cases, a cracked or split tooth, which results in the inevitable loss
of the tooth.
Apart from damage to the natural dentition,
tongue piercings pose similar risks to large operative
procedures and fixed prostheses containing porcelain.
In the patient group there was only one patient with
porcelain crowns. These were placed on the six upper
front teeth. A chipping of the porcelain at the gingival
lingual margins was registered, especially on the four
incisors. This was not due to tooth contact because of
the presence of an open bite.
One person complained of galvanic current during
contact between the stainless steel appliance and an
extensive amalgam filling. As the patient did not want
to remove his ornament, the amalgam was replaced
by a composite filling, which resulted in the dissolution of the pulpal sensitivity.

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