The ofcial journal of the Australian Dental Association

Australian Dental Journal

SCIENTIFIC ARTICLE
Australian Dental Journal 2012; 57: 7178 doi: 10.1111/j.1834-7819.2011.01647.x

Dental and periodontal complications of lip and tongue piercing: prevalence and inuencing factors
A Plessas,* E Pepelassi
*Private Practice, Kielbirnie, North Ayrshire, Scotland. Department of Periodontology, School of Dentistry, The University of Athens, Greece.

ABSTRACT
Background: The aim of this study was to compare the prevalence of lip and tongue piercing complications and explore the effect of ornament time wear period, habits, ornament morphology and periodontal biotype on the development of complications. Methods: One hundred and ten subjects with 110 lip and 51 tongue piercings were assessed for abnormal toothwear and or tooth chipping cracking (dental defects), gingival recession, clinical attachment loss and probing depth of teeth adjacent to the pierced site. Piercing habits (biting, rolling, stroking, sucking) were recorded. Results: Wear time and habits signicantly affected the prevalence of dental defects and gingival recession. Pierced site signicantly affected dental defects prevalence, with greater prevalence for tongue than lip piercing. Wear time signicantly affected attachment loss and probing depth. Attachment loss and probing depth did not signicantly differ between tongue and lip piercings. Gingival recession was signicantly associated with ornament height closure and stem length of tongue ornaments. Periodontal biotype was not signicantly associated with gingival recession, attachment loss and probing depth. Conclusions: Dental defects prevalence is greater for tongue than lip piercing. Gingival recession is similar for tongue and lip piercing. Longer wear time of tongue and lip piercing is associated with greater prevalence of dental defects and gingival recession, as well as greater attachment loss and probing depth of teeth adjacent to pierced sites. Ornament morphology affects gingival recession prevalence.
Keywords: Foreign body complications, gingival recession, oral piercing, periodontal disease, tooth fracture. Abbreviations and acronyms: CAL = clinical attachment loss; CEJ = cemento-enamel junction; GI = gingival index; GR = gingival recession; PPD = probing pocket depth. (Accepted for publication 3 July 2011.)

INTRODUCTION Body art practices, such as tattooing and body piercing, have recently gained popularity among young people.1,2 Body piercing is dened as the penetration of an ornament into openings made in the skin or mucosa.1 It is a very old body modication which in the past was a cultural practice but is today considered a fashion. Intraoral and perioral sites are often selected for piercing with the tongue, lips and cheeks being the most commonly pierced sites. Oral piercing might start as early as adolescence and becomes more popular in college years.3 Oral piercing is not harmless since it entails local and systemic risks. It has been associated with early and late complications. Early complications mainly include pain,4,5 oedema,4,5 haemorrhage5 and inammatory
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reaction5 at the pierced site. Severe complications have also been reported, such as Ludwings angina,2 cerebral abscess6 and endocarditis,7 and airway obstruction.8 Furthermore, the risk of hepatitis and HIV infection cannot be ruled out.5 Late complications are mostly topical and include abnormal toothwear and or tooth chipping cracking9,10 (Fig. 1 and 2), gingival recession10,11 (Fig. 3), localized periodontal destruction,10 cracked tooth syndrome,12 increased salivary ow,9 chewing, speaking and swallowing impairment,4 tissue overgrowth at the pierced site,13 ornament embedment in the tongue,14 generation of galvanic current9 and bid tongue,15 increased concentration of periodontopathogenic bacteria at the pierced site16 and increased prevalence of Candida albicans colonization.17 In addition, ornament ingestion18 and allergic reactions have been reported.
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A Plessas and E Pepelassi effect of the ornament time wear period, habits and ornament morphology on the development of complications. The possible effect of the periodontal biotype on periodontal complications was also examined. MATERIALS AND METHODS One hundred and ten subjects (52 males and 58 females) with age range 18 to 35 years (mean age 21.25 3.55 years) were recruited from the subject pool of four local tattoopiercing studios. The subject inclusion criteria were the presence of intra and or perioral piercing. The exclusion criteria were as follows: known systemic disease or condition; need for medication that could affect the periodontal tissues; pregnancy or lactation; indication for antibiotic prophylaxis; simplied gingival index (GI) 0.30; periodontal defects (clinical attachment loss, periodontal pockets or gingival recession); abnormal toothwear and or tooth chipping cracking in teeth non-adjacent to pierced sites; and dental restorations (llings, crowns, bridges) or high frenum attachment in teeth adjacent to pierced sites. In cases of abnormal tooth wear and or tooth chipping cracking, the subject was asked about the circumstances under which this occurred. Information on possible oral piercing complications was given and removal of oral piercings was advised. Each subject signed an informed consent form prior to enrolment in the study. The study was conducted in accordance with the Helsinki Declaration of 1975, as revised in 2008 and was approved by the Ethics and Research Committee of the School of Dentistry, The University of Athens, Greece. Questionnaire Each subject lled a questionnaire on demographic data, medical and dental history, additional piercing in non-oral locations, oral piercing procedure, reason for oral piercing, time wear of oral ornament, awareness of oral piercing consequences and risks for general health, teeth and gingiva, occurrence of early and late oral piercing complications, ornament removal, ornament care and piercing habits (biting, rolling or sucking the ornament, striking the ornament on the adjacent to teeth). Clinical examination Each patient was subjected to a clinical examination at the Department of Periodontology, School of Dentistry, The University of Athens. The presence of ulcer (Fig. 4) or tissue overgrowth (Fig. 5) at the pierced site was documented. The following parameters were documented for each tooth: decay; abnormal toothwear
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Fig 1. Chipped maxillary central incisor due to oral piercing.

Fig 2. Chipped mandibular rst molar due to oral piercing.

Fig 3. Lingual gingival recession due to tongue piercing.

Studies of the factors inuencing oral piercing complications have focused on specic pierced sites separately, such as the lip10 or tongue.11 Comparisons between lip and tongue piercings in terms of complications have not been thoroughly undertaken. The purpose of the present cross-sectional study was to: (1) assess the prevalence of lip and tongue piercing complications in the dental and periodontal tissues of a population derived from a non-dental setting; (2) compare the prevalence of complications between lip and tongue piercing sites; and (3) explore the possible
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Complications of lip and tongue piercing

Fig 4. Ulcer at the piercing site.

Fig 6. Long stem length tongue ornament.

Fig 5. Tissue overgrowth at the base of the tongue due to piercing.

Fig 7. Size of a long stem length tongue ornament compared to a periodontal probe.

and or tooth chipping cracking; GI;19 clinical attachment loss (CAL); probing pocket depth (PD); and gingival recession (GR). GR was classied by using Millers classication.20 Decay was assessed clinically by using a dental explorer (Asa Dental #0701-12). GI, CAL, PD and GR were assessed at 6 sites for each tooth by using a 15 mm calibrated periodontal probe (PCPUNC015; Hu-Friedy, Chicago, IL, USA). For each tooth adjacent to a pierced site, one CAL, PD and GR value was recorded; the worst CAL, PD and GR value of the dental surface adjacent to the piercing. Whenever more than one tooth adjacent to a pierced site was affected, the measurements concerning the tooth with the worst complications were documented. The periodontal (or gingival) biotype was assessed visually and classied into thin pronounced scalloped and thick at biotype.21 The height of the ornament closure in relation to the cemento-enamel junction (CEJ) of the adjacent tooth and the stem length of the tongue ornaments were also recorded. The ornaments were classied in response to their location into lip (side and middle) and tongue (not tongue frenum) ornaments, in response to wear time (12 months, 1336 months,
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>36 months) and in response to the height of the ornament closure (coronal to the CEJ, at the CEJ level, apical to the CEJ of the adjacent tooth). Tongue ornaments were classied according to the length of their stem into short (<1.59 cm) and long (1.59 cm) stem length ornaments11 (Fig. 6 and 7). The stem length of the tongue ornaments was measured by using calipers. All clinical measurements were performed by the same examiner (AP). Statistical analysis Data were described by ornament item. Continuous variables were expressed as mean standard deviation or median (Q1 Q3) for normally and non-normally distributed variables respectively. Categorical variables were expressed as percentages. X2 or Fishers exact test for small numbers were used to check for associations between categorical variables. Non-parametric Mann Whitney or KruskalWallis tests were applied to examine for differences in continuous variables between two or more groups. Results were considered signicant at the 5% signicance level. The Bonferroni correction
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A Plessas and E Pepelassi was used to adjust p-values for multiple testing. Statistical analysis was performed with the statistical package STATA 9.0 (Stata, College Station, TX, USA). RESULTS Table 1 presents the subject characteristics in terms of piercing. The ornaments were located in the lower lip-side (58 ornaments), lower lip-middle (34 ornaments), upper lip-side (14 ornaments), upper lip-middle (4 ornaments) and tongue (51 ornaments). Seventyeight subjects (71%) presented with piercing in more than one oral site. There were no subjects with piercing on both the tongue and the middle of the lower lip. Selfreported oral piercing complications were as follows: inammation (53 subjects); GR (21 subjects); dentine hypersensitivity (21 subjects); increased salivary ow (15 subjects); taste change (11 subjects); generation of galvanic current (5 subjects); and deposits accumulation (34 subjects). Self-reported immediate postpiercing procedure complications were postoperative pain (in 93 pierced sites); chewing impairment (in 79 pierced sites); speaking impairment (in 54 pierced sites); ornament swallowing (in 78 sites); and severe haemorrhage (in 7 sites). Table 2 shows the percentage of teeth adjacent to pierced sites that presented dental defects in terms of abnormal toothwear and or tooth chipping cracking (32.3%) and GR (39.7%), as well as the mean CAL and PD values of teeth adjacent to pierced sites. In 67 pierced sites (41 lip, 26 tongue; 41.6%), the adjacent tooth had CAL 1 mm, where the mean CAL was 3.4 ( 1.66) mm. In 20 pierced sites (9 lip, 11 tongue; 12.4%), the adjacent tooth presented CAL 2 mm with mean CAL 5.35 ( 1.66) mm. In 15 pierced sites (6 lip, 9 tongue; 9.3%), the adjacent tooth presented PD >3 mm with mean PD 4.42 ( 1.22) mm. A PD of 5 mm was found in 5 teeth adjacent to pierced sites (2 lip, 3 tongue) with mean PD 5.75 ( 1.79) mm. The mean time wear period was 30.3 ( 30.9) months (range 1 to 144 months). Ornaments are presented by group of time wear in Table 2. The time period of ornament wear affected the prevalence of soft tissue defects at the pierced site, dental defects and soft tissue defects in the pierced site and GR as well as CAL and PD values (Table 2). Prevalence of dental defects for time wear 12 months was statistically signicantly lower than for >36 months (p = 0.001 and p < 0.001, respectively) and for 1336 months (p = 0.02 and p = 0.001 respectively). Prevalence of GR recession was signicantly lower for time wear 12 months than for >36 months (p < 0.001) and for 1336 months than for >36 months (p = 0.02). CAL values were signicantly greater for time wear >36 months than for 12 months (p < 0.001) and 1336 months (p = 0.002). PD values for time wear 12 months were signicantly lower than for >36 months (p = 0.003) and marginally signicantly lower than for 13 36 months (p = 0.06). Soft tissue overgrowth at the pierced site was observed only at the base of the tongue in subjects with tongue piercing. The mean GR depth for affected teeth adjacent to ornaments was 2.67 ( 1.02) mm. Respective values for time wear 12, 1336 and >36 months were 2.65 ( 1.58) mm, 2.73 ( 1.55) mm and 2.11 ( 1.22) mm. There were no statistically signicant differences among them. Ten (15.6%) GR defects were Miller Class II with mean depth 4.3 ( 1.15) mm. The wear time was between 13 to 36 months for 4 defects and >36 months for 6 defects. The rest, 54 (84.4%), were Miller Class I defects. All piercing habits, except sucking, were statistically signicantly associated with the presence of dental defects (Table 3). For lip piercing, sucking was positively associated with the presence of GR (Table 3). The presence of GR was statistically signicantly associated with the height of the ornament closure in
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Table 1. Subject characteristics concerning piercing (n = 110)

Parameters n % 81.8 12.7 4.5 0.9 63.7 23.7 6.3 3.6 2.7 29.1 70.9 73.6 26.4 50.9 49.1 35.5 64.5 50 50 11 9 30 17.3 12.7

Piercing procedure Piercing studio 90 Self performed 14 Jewellery store 5 Medical doctor 1 Reason for piercing Cosmetics 70 Concept, self-expression 26 Sexual 7 Social grouping 4 Peer pressure fashion 3 Awareness of oral piercing consequences for: General health Yes 32 No 78 Teeth Yes 81 No 29 Gingiva Yes 56 No 54 Piercing location Only oral piercing 39 Oral and non-oral piercing 71 Ornament removal Yes 55 No 55 Reason for ornament removal Dental visit 12 Physical exercise 10 Ornament cleaning 33 Method of ornament cleaning Antimicrobial solution 19 Brushing 14 n = number of subjects. % = % of subjects.
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Complications of lip and tongue piercing Table 2. Dental and soft tissue defects in the pierced site, GR, CAL and PD by group of time wear
Parameters In total (n = 161) (n%) Dental defects No Yes Soft tissue defects No Ulcer Tissue overgrowth GR No Yes CAL (mm) PD (mm) 109 (67.7) 52 (32.3) 61 (37.9) 88 (54.7) 12 (7.5) 97 (60.3) 64 (39.7) Mean SD 2.04 1.60 2.46 0.93 12 m (n = 58) (n%) 48 (82.8) 10 (17.2) 37 (63.8) 20 (34.5) 1 (1.7) 44 (75.7) 14 (24.1) Mean SD 1.5 1.1 2.2 0.8 Time period of wear 1336 m (n = 61) (n%) 39 (63.9) 22 (36.1) 18 (29.5) 39 (63.9) 4 (6.6) 37 (60.7) 24 (39.3) Mean SD 1.9 1.4 2.4 0.8 >36 m (n = 42) (n%) 22 (52.4) 20 (47.6) 6 (14.3) 29 (69.1) 7 (16.7) 16 (38.1) 26 (61.9) Mean SD 2.9 2.1 2.8 1.1 0.004** <0.001** p-value

0.001**

<0.001* <0.001*

* = p-values were obtained by using KruskalWallis test. ** = p-values were obtained by using X2 test. n = number of ornaments. % = % of ornaments. = clinical attachment loss. = probing pocket depth. m = months.

Table 3. Defects by piercing habits

Habits No (n = 109) n (%) Biting No Yes Rolling No Yes Striking No Yes Sucking No Yes 39 (81.3) 70 (62.0) 102 (72.9) 7 (33.3) 97 (70.8) 12 (50.0) 75 (67.6) 34 (68.0) Dental defects Yes (n = 52) n (%) 9 (18.2) 43 (38.0) 38 (27.1) 14 (66.7) 40 (29.2) 12 (50.0) 36 (32.4) 16 (32.0) GR* No n = 70 n (%) Sucking No Yes 44 (73.3) 26 (52.0) Yes n = 40 n (%) 16 (26.7) 24 (48.0) 0.02 x2, p-value 0.02 <0.001 0.04 0.96 x2, p-value

* = Restricted to lip piercing. n = number of ornaments. % = % of ornaments.

relation to the CEJ of the adjacent teeth (Table 4). In the presence of GR, for 84.1% of the ornaments the height of the closure was at the CEJ level. In the absence of GR, for 43.9% of the ornaments the height of the closure was apically to the CEJ level (Table 4). The mean CAL values differed signicantly between the closure group at the CEJ level and the closure group
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coronally to the CEJ, as well as between the closure group at the CEJ level and the closure group apically to the CEJ (p = 0.0001, for both comparisons). These associations applied for PD values as well (p = 0.0001 and p = 0.004, respectively) (Table 4). In terms of screw cap material, 158 (98.1%) ornaments had metal screw cap; the rest (3; 1.9%) had acrylic screw cap. Therefore, exploration of the possible effect of ornament screw cap material was not feasible. The periodontal biotype was not statistically significantly associated with the presence of GR, CAL and PD values (Table 4). For tongue piercing, the presence of GR was statistically signicantly associated with long stem length (Table 5). The pierced site (lip, tongue) was associated with the presence of dental defects but it was not associated with the presence of GR, PD and CAL values (Table 6). For GR defects, all lingual defects were associated with tongue piercings and all buccal defects with lip piercings. PD and CAL values did not differ signicantly between the tongue and lip piercing groups (z = 1.8, p = 0.06 and z = 1.5, p = 0.12 respectively) (Table 6). Stratication of data in relation to the time period of ornament wear revealed that for wear time 12 months, the presence of dental defects, GR, PD and CAL values were not statistically signicantly associated with the pierced site. For time wear between 13 and 36 months and 36 months, there was statistically signicant association between the pierced site and dental defects with greater prevalence of defects for the tongue group. The same applied for GR for time wear between 13 and 36 months with greater prevalence of GR in the tongue group (Table 6).
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A Plessas and E Pepelassi Table 4. GR, CAL and PD by height of the ornament closure in relation to CEJ and by periodontal biotype
Parameters Height of the closure in relation to CEJ Coronal (n = 36) n (%) GR No Yes CAL (mm) PD (mm) 33 (33.7) 3 (4.8) Mean SD 1.2 0.5 2.0 0.6 At the (n = 75) n (%) 22 (22.44) 53 (84.1) Mean SD 2.7 1.8 2.8 1.1 Apical to (n = 50) n (%) 43 (43.9) 7 (11.1) Mean SD 1.6 1.3 2.3 0.7 <0.001*** p-value Periodontal biotype Thin (N = 70) N (%*) 37 (52.9) 33 (47.1) Mean SD 2.1 0.2 2.4 0.1 Thick (N = 40) N (%*) 27 (67.5) 13 (3.5) Mean SD 2.1 0.3 2.4 0.1 0.13*** p-value

<0.001*** <0.001*

0.36** 0.78**

* = p-values were obtained by using KruskalWallis test. ** = p-values were obtained by using MannWhitney test. *** = p-values were obtained by using X2 test. n = number of ornaments. % = % of ornaments. N = number of subjects. %* = % of subjects. = clinical attachment loss. = probing pocket depth.

Table 5. Dental defects, GR, CAL and PD by stem length group

Parameters Dental defects Stem length* Short (n = 38) n (%) No Yes GR No Yes CAL (mm) PD (mm) 21 (55.3) 17 (44.7) n (%) 23 (60.5) 15 (39.5) Mean SD 2.2 0.3 2.6 0.2 Long (n = 13) n (%) 6 (46.2) 7 (53.8) n (%) 4 (30.8) 9 (69.2) Mean SD 3 0.7 2.7 0.2 0.06*** 0.57*** p-value

0.16** 0.40**

* = Restricted to tongue piercing. ** = p-values were obtained by using MannWhitney test. *** = p-values were obtained by using X2 test. n = number of tongue ornaments. % = % of tongue ornaments. = clinical attachment loss. = probing pocket depth.

DISCUSSION The present cross-sectional study assessed the complications of intraoral and perioral piercing on the dental and periodontal tissues in a group of 110 subjects with mean age 21.25 ( 3.55 years). A total of 161 pierced sites were evaluated with mean time of ornament wear 30.3 ( 30.9) months. Most subjects had more than one intraoral and perioral pierced site, therefore the ornament instead of the patient was the unit of statistical analysis. For most subjects the piercing procedure was performed in a piercing studio (81.8%), while only one subject had the piercing performed by a medical
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doctor. The present ndings are in accordance with results by Garcia-Pola et al. 22 who found that 80.8% of piercing procedures were performed in a piercing studio and by Kieser et al.23 who reported that only 9.3% of subjects had their piercing performed by a medical doctor or dentist. Cosmetics was the main reason for piercing in the present study which is consistent with Garcia-Pola et al.22 It is important to note that less than one-third of the present pierced subjects cleaned the ornament regularly. The present study revealed that a signicant percentage of pierced subjects were not aware of the oral health consequences of piercing and were better informed of the possible piercing consequences for teeth rather than the gingiva. The high prevalence of postoperative pain and the low prevalence of postoperative severe haemorrhage found in the present study was in accordance with Garcia-Pola et al.22 The percentage of subjects who reported complications is higher in the present study than in the Kieser et al. study.23 Inammation was the most frequently self-reported complication for the present subject population. The present ndings on increased salivary ow rate, as self-reported, are in accordance with the ndings of Venta et al.3 who objectively assessed salivary ow. In the present study, almost one-third of teeth adjacent to pierced sites presented abnormal toothwear and or tooth chipping cracking and more than onethird of teeth adjacent to pierced sites presented with GR. Prevalence of abnormal toothwear and or tooth chipping cracking was greater for tongue than lip piercing, although prevalence of GR was similar for tongue and lip piercing. Vilchez-Perez et al.24 demonstrated that prevalence of GR, abnormal toothwear, tooth fractures and cracks was higher at the pierced than the unpierced side of the lip. Leichter and
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Complications of lip and tongue piercing Monteith25 and Kapferer et al.10 reported greater GR prevalence in subjects with lip piercing than in unpierced subjects. Both Kieser et al.23 and Kapferer et al.10 failed to nd a signicant association between piercing and abnormal toothwear. In the present study, the time period of ornament wear affected the condition of the soft tissues at the pierced site and the condition of the dental and periodontal tissues of teeth adjacent to the pierced sites, as statistically signicant differences (in the prevalence of dental, soft tissue and periodontal defects) were detected among the three time wear periods (12 months, 1336 months, >36 months). A signicant association between time wear and buccal GR has previously been reported by Kapferer et al.10 For the affected sites, the mean GR depth found in the present study (2.65 mm) was similar to that reported by Campbell et al. (2.53 mm).11 Most of the recession defects were Miller Class I defects; only a few were Miller Class II. The percentage of Miller Class II defects (15.64%) found here is consistent with that reported by Leichter and Monteith25 for Miller Class II and III defects (18.7%). In the present study, there was a signicant positive association between the stem length of the tongue piercing and the presence of GR, which is consistent with results by Campbell et al.11 The present ndings of the existence of an association between the presence of GR and ornament closure in relation to the CEJ of the adjacent teeth are in accordance with previous ndings by Kapferer et al.10 Furthermore, the present ndings and the results by Kapferer et al.10 are consistent in the absence of a signicant association between the periodontal biotype and the prevalence of GR. The present ndings of the effect of piercing habits on dental defects and GR cannot be compared to previous ndings since, to the authors knowledge, this question has not yet been addressed in the literature. The present study has limitations, mainly concerning the lack of an unpierced control subject group, which would have allowed for comparisons of abnormal toothwear, tooth chipping cracking, gingival margin level and CAL. Dentists should inform patients, especially younger patients, of oral piercing consequences for teeth and the gingiva, and advise them to avoid or remove oral piercings. In cases where the patient chooses oral piercings despite being advised to the contrary, it is the dentists responsibility to educate the patient on proper ornament care and regular professional oral monitoring. The patient should be informed that the longer the wear time, the greater the chance to present with oral complications and that piercing habits increase the possibility of developing dental defects and GR. Pierced patients should be recalled frequently to ensure early detection of possible dental or
77 27 15 Mean SD Mean SD No Yes No Yes No Yes No Yes No Yes No Yes n Mean SD Mean SD Mean SD Mean SD 110 28 6 51 20 4 0.92** Lip 82 28 Tongue 27 24 p-value 0.006** 70 40 27 24 0.20** 1.9 1.3 2.4 2.0 0.12* No Yes No Yes 2.3 0.7 2.7 1.2 0.06* n 26 8 18 6 0.90** * = p-values were obtained by using MannWhitney test. ** = p-values were obtained by using Fishers exact test. *** = p-values were obtained by using KruskalWallis test. CAL = clinical attachment loss. PD = probing pocket depth. n = number of ornaments. DD = dental defects. GR = gingival recession. n n Mean SD Mean SD n 1.5 0.9 1.6 1.3 0.85* 2.2 0.7 2.3 0.9 0.35* 34 36 13 24 3 9 0.002** n 33 4 4 8 0.03** n 1.8 1.4 2.4 1.4 0.06* 2.3 0.8 2.8 1.1 0.17* 49 18 9 12 4 11 0.01** n 11 16 5 10 0.64** 2.5 1.5 3.7 2.7 0.22*** 2.5 0.8 3.3 1.5 0.08*** n Time wear >36 months Time wear 1336 months Time wear 12 months In total (irrespective of time wear) Pierced site

Table 6. Pierced site and defects per time period of wear

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DD

GR

CAL (mm)

PD (mm)

DD

GR

CAL (mm)

PD (mm)

DD

GR

CAL (mm) PD (mm)

DD

GR

CAL (mm)

PD (mm)

A Plessas and E Pepelassi periodontal complications. The dentist should document the existence of piercings and their characteristics concerning location, wear time, habits and long tongue piercing stem length. Long wear time increases the possibility of both dental defects and GR. Dental defects are more frequent with tongue piercing, whereas GR is similarly frequent for tongue and lip piercing. Long stem length tongue ornaments have a greater potential to cause GR. CONCLUSIONS Within the limitations of the present study, the following conclusions could be drawn: approximately one-third of teeth adjacent to pierced sites present abnormal tooth wear and or tooth chipping cracking or GR. The prevalence of abnormal tooth wear and or tooth chipping cracking is greater for tongue than lip piercing. The prevalence of GR is similar for tongue and lip piercing. Longer wear time of tongue and lip piercing is associated with greater prevalence of abnormal tooth wear and or tooth chipping cracking and GR, as well as greater attachment loss and probing pocket depth of teeth adjacent to pierced sites. The stem length of the tongue ornament and the height of the ornament closure in relation to the CEJ of the adjacent teeth affects the prevalence of GR. REFERENCES
1. Armstrong ML. You pierced what? Ped Nurs 1996;22:236 238. 2. Perkins CS, Meisner J, Harrison JM. A complication of tongue piercing. Br Dent J 1997;182:147148. 3. Venta I, Lakoma A, Haahtela S, Peltola J, Ylipaavelniemi P, Turtola L. Oral piercing among rst-year university students. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:546549. 4. Farah CS, Harmon DM. Tongue piercing: case report and review of current practice. Aust Dent J 1998;43:387389. 5. Lopez-Jornet P, Navarro-Guardiola C, Camacho-Alonso F, Vicente-Ortega V, Yanez-Gascon J. Oral and facial piercings: a case series and review of the literature. Int J Dermatol 2006; 45:805809. 6. Martinello RA, Cooney EL. Cerebellar brain abscess associated with tongue piercing. Clin Infect Dis 2003;36:3234. 7. Lick SD, Edozie SN, Woodside KJ, Conti VR. Streptococcus viridians endocarditis from tongue piercing. J Emerg Med 2005;29:5759. 8. Trachsel D, Hammer J. A vote for inhaled adrenaline in the treatment of severe upper airway obstruction caused by piercing of the tongue in hereditary angioedema. Intensive Care Med 1999;25:13351336. 9. Price SS, Lewis MW. Body piercing involving oral sites. J Am Dent Assoc 1997;128:10171020. 10. Kapferer I, Benesch T, Gregoric N, Ulm C, Hienz SA. Lip piercing: prevalence of associated and contributing factors. A cross-sectional study. J Periodontal Res 2007;42:177183. 11. Campbell A, Moore A, Williams E, Stephens J, Tatakis DN. Tongue piercing: impact of time and barbell stem length on lingual gingival recession and tooth chipping. J Periodontol 2002;73:289297. 12. Di Angelis AJ. The lingual barbell: a new etiology for cracked tooth syndrome. J Am Dent Assoc 1997;128:14381439. 13. Boardman R, Smith RA. Dental implications of oral piercing. J Calif Dent Assoc 1997;25:200207. 14. Shacham R, Zaguri A, Librus HZ, Bar U, Eliav E, Nahlieli O. Tongue piercing and its adverse effects. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:274276. 15. Fleming PS, Flood TR. Bid tongue a complication of tongue piercing. Br Dent J 2005;198:265266. 16. Ziebolz D, Hornecker E, Mausberg RF. Microbiological ndings at tongue piercing sites: implications to oral health. Int J Dent Hyg 2009;7:256262. 17. Zadik Y, Burnstein S, Derazne E, Sandler V, Lanculovici C, Halperin T. Colonization of Candida: prevalence among tonguepierced and non-pierced immunocompetent adults. Oral Dis 2010;16:172175. 18. Stead LR, Williams JV, Williams AC, Robinson CM. An investigation into the practice of tongue piercing in the South West of England. Br Dent J 2006;200:103107. 19. Lindhe J. Textbook of Clinical Periodontology. Copenhagen: Munskgaard, 1981:327352. 20. Miller PD. A classication of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5:913. 21. Becker W, Ochenbein C, Tibbets L, Becker BE. Alveolar bone anatomic proles as measured from dry skulls. J Clin Periodontol 1997;24:727731. 22. Garcia-Pola MJ, Garcia-Martin JM, Varela-Centelles P, BilbaoAlonso A, Cerero-Lapiedra R, Seoane J. Oral and facial piercing: associated complications and clinical repercussion. Quintessence Int 2008;39:5159. 23. Kieser JA, Thomson WM, Koopu P, Quick AN. Oral piercing and oral trauma in a New Zealand sample. Dent Traumatol 2005;21:254257. 24. Vilchez-Perez MA, Fuster-Torres MA, Figueiredo R, ValmasedaCastellon E, Gay-Escoda C. Periodontal health and lateral lower lip piercings: a split-mouth cross-sectional study. J Clin Periodontol 2009;36:558563. 25. Leichter JW, Monteith BD. Prevalence and risk of traumatic gingival recession following elective lip piercing. Dent Traumatol 2006;22:713.

Address for correspondence: Eudoxie Pepelassi Department of Periodontology School of Dentistry The University of Athens 2 Thivon Street Athens 115 27 Greece Email: epepela@dent.uoa.gr

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