CLINICAL PRACTICE
CASE REPORT |
CASE REPORT
Treatment of a mucogingival defect associated with intraoral piercing
KRISTI M. SOILEAU, D.D.S., M.Ed.
 |
ABSTRACT
|
|---|
Background. In the previous decade, a notable increase in body adornment through tattooing and piercing has been a cause for concern among both dental and medical professionals. The author reports on the clinical consequences of wearing oral jewelry, specifically periodontal injury that requires surgical intervention. She also presents a general literature review of dental and medical consequences of wearing oral jewelry.
Case Description. A 20-year-old woman with a tongue piercing had severe periodontal recession in lingual aspect of the mandibular incisal area proximal to the location of the oral jewelry. The author used a connective tissue graft to correct the defect via root coverage and an addition to the gingival width.
Clinical Implications. Wearing intra-oral jewelry can lead to the development of severe mucogingival defects and necessitates careful and comprehensive periodontal evaluations on a regular basis to monitor attachment loss and damage to dental structures. Patients must be educated about these risks through counseling, patient information brochures and individual case documentation.
Key Words: Oral jewelry; connective tissue grafting; mucogingival defect; complications
In the past 10 years, a notable increase in body adornment through tattooing and piercing has been a cause for concern among both dental and medical professionals. Of most concern to periodontists is the practice of intraoral and perioral piercing. The most commonly pierced intraoral sites are the lips (38 percent) and tongue (8 percent).1 Less frequently pierced intraoral locations are the cheek, uvula and lingual frenum.2 As many as 10.5 percent of 446 undergraduate university students surveyed admitted to having had their tongues pierced.3
Wearing intraoral jewelry can lead to the development of severe mucogingival defects.
Dental professionals have noted several risks associated with the piercing of oral tissues. In a survey of more than 400 pediatric dentists, almost 23 percent claimed to have dealt with complications associated with oral piercing, the most common of which was damage to teeth.4 This includes injuries such as chipping or fracturing of teeth and pulpal involvement.5–7
In the last eight years, several cases of piercing-associated gingival recession and attachment loss have been documented.1,6–17 Boardman and Smith1 reported that 12.5 percent of people with oral piercing claimed that they had injuries associated with lip piercing, and 7.8 percent claimed they had injuries associated with tongue jewelry. Campbell and colleagues7 reported a higher incidence (19.2 percent) of gingival lesions caused by tongue jewelry. They also found a cause-and-effect relationship between the barbell stem length, the duration for which the unit was in the mouth and lingual gingival recession.
Dentists have used grafts to correct mucogingival defects for decades. The reconstruction of damaged periodontal tissue has taken on an increasingly important role in surgical periodontics. The restorative dentist should consider reconstructing damaged periodontal structures before recommending esthetic or functional bonding or altering pontic design. In cases of gingival recession, root coverage procedures can create a naturally esthetic result that blends with adjacent tissue. The tissue to be grafted typically is taken from the roof of the mouth, though using donor tissue is an option. To idealize root coverage results, bonding of any residual defects that occur after grafting procedures may be necessary. The development of the connective tissue graft has enhanced our ability to restore form and function in a manner not possible before.
In this study, I present a case report about one patient’s experience with localized gingival recession caused by oral piercing. I also explain a technique that can be used to correct and manage such a defect.
|
CASE REPORT
|
|---|
A 20-year-old woman sought dental care at a private dental practice in New Orleans for isolated areas of gingival bleeding. She was medically healthy and was taking no medications. She was smoking 1.5 packs of cigarettes per day.
The clinical examination revealed a dome, or pierced barbell, in the tongue that had been present for four years (Figure 1
). I noted a 6-millimeter gingival recession defect on the lingual aspect of the mandibular right central incisor (Figure 2) and a lack of attached gingiva associated with the defect. The level of attached gingiva on the lingual aspect of the adjacent central incisor was 4 mm, representing 1 mm of recession. Using the cementoenamel junction as a baseline, I found that the mandibular lateral incisor also exhibited 1 mm of lingual recession, while the recession on the premolars and molars ranged from no recession to 1 mm of excess gin-giva. The probing depths on all four mandibular incisors measured 2 to 3 mm. I noted no mobility on any of the patient’s 28 noncarious teeth.
View larger version (84K):
[in this window]
[in a new window]
|
Figure 2. A 6-millimeter cleftlike defect on the gingival near the lingual aspect of tooth no. 25 (arrow), resulting from wearing the oral jewelry.
| |
Several restorations needed replacement, so I referred her to a restorative dentist in New Orleans. There was slight rotation of all four maxillary incisors; otherwise, the dentition was well-aligned and in desirable function. The patient’s overbite was 0 mm, her overjet was 1 mm, and fremitus was absent. She did not have a crossbite. A periapical radiograph revealed 0 to 5 percent bone loss in the area of the mandibular incisors.
The patient underwent periodontal scaling, polishing and fluoride treatment, and I advised her to undergo periodontal connective tissue grafting to correct the mucogingival defect on the lingual aspect of tooth no. 25. I educated the patient about the harm-causing potential of the tongue jewelry, and she agreed to remove it permanently.
She received pre- and postoperative instructions, as well as prescriptions for alprazolam 0.5 milligram, doxycycline 100 mg and propoxyphene N-100. Ten weeks later, she presented for surgical therapy as recommended. Her oxygen saturation was 98 percent, her pulse was 69 beats per minute, and her blood pressure was 118/60 mm of mercury. There was no documented change in her medical history, and she had taken her medications as directed.
I injected her with one carpule of 2 percent xylocaine with 1:100,000 epinephrine and one carpule of 0.5 percent marcaine with 1:200,000 epinephrine. I prepared the mucoperiosteal bed by removing the epithelial layer around the defect on the lingual aspect of tooth no. 25 and extending the incision to the gingiva of the adjacent teeth for increased blood supply to the graft using a 12B blade.
I removed an 11-mm long x 8-mm wide connective tissue graft from the palatal area, approximately 3 mm from the free gingival margin of teeth nos. 3 through 5. Keeping the epithelial collar, I placed the connective tissue graft over the mucoperiosteal bed of the lingual aspects of teeth nos. 24 through 26 (Figure 3) using 6-0 chromic gut sutures. I injected 1 cubic centimeter of dexamethasone (4 mg/milliliter) into the surgical donor and recipient sites for pain and swelling management. I applied a periodontal dressing on the lingual aspect of the mandibular anterior incisors and a surgical stent over the palatal wound.
I reviewed the postoperative instructions with the patient. The patient returned at one week postoperative for observation and to have her dressing removed. I instructed her to use dental sponges dipped in a 0.2 percent chlorhexidine mouthrinse to cleanse the surgical sites. I also instructed her to not brush the tooth or floss the graft recipient site at this time. Healing was uneventful. The following week, I performed a postoperative prophylaxis on all teeth and instructed the patient to use an extrasoft brush dipped in the mouthrinse at this point, and gentle flossing and brushing were to be instituted by the patient in the surgical site. Two weeks later, I performed a second prophylaxis and placed the patient on a three-month recall program, owing to early furcation involvement and isolated 5-mm pocketing around molars.
At 14 months postoperatively, the probing depth measured 2 to 3 mm on the lingual aspect of teeth nos. 22 through 26; mobility remained absent, while the gingival width on the lingual aspect of tooth no. 25 measured 4 mm, and the recession measured 0.5 mm. This indicated an increase in gingival width from presurgical levels of 4 mm and an improvement in recession of 5.5 mm (Figure 4).
|
DISCUSSION
|
|---|
Brooks and colleagues18 found 39 documented cases of gingival recession from the increasingly popular behavior of intraoral piercing. They created a demographic profile of mucogingival defects induced by intraoral and perioral piercing (Box). In three other cases, six gingival lesions were attributed to both tongue and lip jewelry in three sites. This brings the total number of affected gingival sites to 43, including the case I report in this article.
One case described by Dibart and colleagues15 reported two recession sites—one on the facial aspect and one on the lingual aspect of a tooth—as a result of tongue and lip piercing. Brooks and colleagues’ excluded two cases reported by Sardella and colleagues17 from their profile, as the clinical presentation of recession in these cases suggested pre-existing conditions: one with localized root staining and one with generalized marginal inflammation with apparent localized root planing.
Brooks and colleagues’ profile showed that the majority of piercing-associated lesions involved the use of tongue jewelry (64.3 percent of affected sites) and lip jewelry (35.7 percent of affected sites). The area of recession most frequently associated with tongue piercing was the lingual aspect of teeth nos. 24 and 25 (75 percent of total specified sites). Specified injuries caused by lip jewelry were localized to the facial aspect in tooth no. 25 (58.3 percent of cases reported) and in the area of teeth nos. 24 and 25 (41.7 percent of cases reported).18
Typically, the earlier the detection of attachment loss, recession or both, the more predictable is the treatment for regenerating attachments. Frequently, narrow, cleftlike defects develop on the lingual aspect of the mandibular incisors,15 with recession depths of 2 to 3 mm or more often extending beyond the mucogingival junction.7 Thicker gingival tissues may be more impervious to recession than thinner gingival tissues.19–21 The use of tissue grafting to correct defects has proven to be a long-term, successful means of correcting mucogingival defects, and, as the case in this article shows, it also may address periodontal concerns caused by intraoral piercing.
Several articles report that the consequences of wearing oral jewelry include chipped or fractured teeth, edema, inflammatory or neurological damage at the site of piercing, difficulty chewing, foreign body reaction, pain, infection, dysphagia, speech interferences, scarring, lymphadenitis, sialadenitis, calculus formation on the jewelry, metallic sensitivity and hypersalivation.1,23–29 Medical complications may include Ludwig’s angina, brain abscess, swallowing and aspiration of jewelry, excessive bleeding, airway obstruction, tetanus and hepatitis.
|
CONCLUSION
|
|---|
Periodontists play a vital role in detecting defects associated with perioral and intraoral piercing, as well as in treating such defects with grafting techniques. Dentists need to become more involved in raising public awareness about the risks associated with oral piercing. They need to make concerted efforts to prevent medical and dental sequelae.
|
FOOTNOTES
|
|---|
Dr. Soileau maintains a private practice in periodontics, 2820 Napoleon Ave., Suite 470, New Orleans, La. 70115. Address reprint requests to Dr. Soileau.
|
REFERENCES
|
|---|
- Boardman R, Smith RA. Dental implications of oral piercing. J Calif Dent Assoc 1997;25:200–7.[Medline]
- Price SS, Lewis MW. Body piercing involving oral sites. JADA 1997;128:1017–20.[Abstract/Free Full Text]
- Mayers LB, Judelson DA, Moriarty BW, Rundell KW. Prevalence of body art (body piercing and tattooing) in university undergraduates and incidence of medical complications. Mayo Clin Proc 2002;77(1): 29–34.[Abstract/Free Full Text]
- Croll TP. ‘Wrecking ball’ dental fractures: report of 2 cases. Quintessence Int 1999;30:275–7.[Medline]
- Bassiouny MA, Deem LP, Deem TE. Tongue piercing: a restorative perspective. Quintessence Int 2001;32:477–81.[Medline]
- De Moor RJ, De Witte AM, De Bruyne MA. Tongue piercing and associated oral and dental complications. Endod Dent Traumatol 2000;16:232–7.[Medline]
- 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;73:289–97.[Medline]
- Harnick DJ. Case report: gingival abrasion due to a ‘chin ring.’ J Gen Orthod 1998;9(1):25–6.[Medline]
- Er N, Ozkavaf A, Berberoglu A, Yamalik N. An unusual cause of gingival recession: oral piercing. J Periodontol 2000;71:1767–9.[Medline]
- Panagakos FS, Linfante, Pascuzzi JN. Attachment loss associated with the presence of a tongue bar: a case report. Gen Dent 2000;48:454–6.[Medline]
- Lausten LL, Koening L. Differential diagnosis and clinical management of external resorption of lingual root surfaces of mandibular incisors and related soft tissue pathoses related to tongue stud trauma (abstract). Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:450.
- Peticolas T, Tilliss TS, Cross-Poline GN. Oral and perioral piercing: a unique form of self-expression. J Contemp Dent Pract 2000;1(3):30–46.[Medline]
- Sadiq SK. piercing difficulties (letter). Br Dent J 2001;190(4):170.[Medline]
- Kretchmer MC, Moriarty JD. Metal piercing through the tongue and localized loss of attachment: a case report. J Periodontol 2001;72:831–3.[Medline]
- Dibart S, De Feo P, Surabian G, Hart A, Capri D, Su MF. Oral piercing and gingival recession: review of the literature and a case report. Quintessence Int 2002;33(2):110–2.[Medline]
- O’Dwyer JJ, Holmes A. Gingival recession due to trauma caused by a lower lip stud. Br Dent J 2002;192:615–6.[Medline]
- Sardella A, Pedrinazzi M, Bez C, Lodi G, Carrassi A. Labial piercing resulting in gingival recession: a case series. J Clin Periodontol 2002;29:961–3.[Medline]
- Brooks JK, Hooper KA, Reynolds MA, Formation of mucogingival defects associated with intraoral and perioral piercing: case reports. JADA 2003;134:837–43.[Abstract/Free Full Text]
- Wennström JL. The significance of the width and thickness of the gingiva in orthodontic treatment. Dtsh Zahnärztl Z 1990;45(3):136–41.
- Tenenbaum H, Tenenbaum M. A clinical study of the width of the attached gingiva in the deciduous, transitional and permanent dentitions. J Clin Periodontol 1986;13:270–5.[Medline]
- Müller HP, Eger T, Schorb A. Gingival dimensions after root coverage with free connective tissue grafts. J Clin Periodontol 1998;25:424–30.[Medline]
- Müller HP, Eger T. Masticatory mucosa and periodontal phenotype: a review. Int J Periodontics Restorative Dent 2002;22(2):172–83.[Medline]
- Ng KH, Siar CH, Ganesapillai T. Sarcoid-like foreign body reaction in body piercing: a report of two cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84(1):28–31.[Medline]
- Farah CS, Harmon DM. Tongue piercing: case report and review of current practice. Aust Dent J 1998;43:387–9.[Medline]
- Botha PJ. Lingual piercing. SADJ 1998;53:453–4.[Medline]
- Olsen JC. Lingual abcess secondary to body piercing. J Emerg Med 2001;20:409.[Medline]
- Folz BJ, Lippert BM, Kuelkens C, Werner JA. Hazards of piercing and facial body art: a report of three patients and literature review. Ann Plast Surg 2000;45:374–81.[Medline]
- Folz BJ, Lippert BM, Kuelkens C, Werner JA. Jewelry-induced diseases of the head and neck. Ann Plast Surg 2002;49:264–71.[Medline]
- Shacham R, Zaguri A, Librus HZ, Bar T, Eliav E, Nahlieli O. Tongue piercing and its adverse effects. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:274–6.[Medline]
TOP
ABSTRACT
CASE REPORT
