Ethnobotanical tattooing of the gingiva
Literature review and report of a case
John K. Brooks, DDS and
Mark A. Reynolds, DDS, PhD
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ABSTRACT
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Background. Traditional gingival tattooing, practiced in Ethiopia and occasionally in other African and Middle Eastern nations, is performed for esthetic appeal or superstition, and it occasionally may be used as a homeopathic remedy for dental diseases. The authors provide a literature review and case report of this oral custom.
Case Description. A 54-year-old woman from Ethiopia reported that she had undergone tattooing of the maxillary gingiva six years previously for analgesic management of undisclosed oral disease. The gingiva was pierced with a needle, tipped with lantern soot and resin from the plant Datura stramonium (an herb that possesses potent anticholinergic tropane alkaloids and has demonstrated in vitro antimicrobial activity). However, the patient admitted that this procedure had provided no reduction in the pain. Clinical examination was significant for a pronounced blue pigmentation of the maxillary gingiva, generalized mild periodontitis and several carious lesions.
Clinical Implications. Practitioners should ascertain whether gingival tattooing had been performed when patients manifest unusual oral pigmentation and be aware of its use in folk medicine for various oral conditions.
Key Words: Gingival tattooing; Datura stramonium; ethnobotanical; cultural body modification; oral pain; Ethiopia
Intentional placement of tattoos within the oral facial region is encountered infrequently in clinical practice. The uses of intraoral implantation of exogenous pigmentation are diverse: tribal and gang identification, expressions of love, bonding and cosmetic enhancement. Occasionally, clinicians may perform medical tattooing for the management of gingival vitiligo1; the achievement of color matching following lip reconstruction2; the establishment of the progress of orthodontic treatment3; the marking of oral sites for planned cleft lip and palate surgery,4 oncologic surgery and selective radiotherapy5; the forensic identification of juveniles6; and the localization of uncovered dental implants.7
The ethnic custom of gingival tattooing for beautification is performed commonly by laypeople and, rarely, by clinicians in Ethiopia and other African and some Middle Eastern nations; at least 17 case reports have appeared in the English language literature.8–15 Preteen and teenaged girls typically undergo gingival tattooing, resulting in blue pigmentation on the facial aspects of the maxillary gingiva. The intent of the tattooing process is to mask the physiological pink-to-red color of the gingiva, which traditionally is considered unhealthy in appearance. Fewer teenaged boys participate in this ritual, and it usually is confined to the gingiva of the maxillary canine regions.8,14 Approximately 60 to 80 percent of teen-aged girls and women repeat the tattooing procedure, whereas 20 percent of participants choose to undergo this process at least three times.10 A questionnaire given to Kanuri women in Nigeria revealed the widespread practice of orofacial tattooing, with 41 percent (201 of 495) of respondents having lip tattoos, 2 percent (12 of 495) having lip and gingival tattoos, and 1 percent (five of 495) having gingival tattoos.16
Throughout history, people from all cultures have sought use of folk medicine to treat a constellation of dental ailments. Scant information, however, is available with regard to the therapeutic application of herbal preparations administered with oral tattooing for the treatment of oral pain. Here we present a previously undescribed method of pain management involving the practice of gingival tattooing associated with the use of resin derived from the plant Datura stramonium and combined with lantern soot.
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CASE REPORT
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A 54-year-old woman from Shenkora, Ethiopia, affiliated with the Amhara culture, sought dental care at the emergency clinic of the Dental School, University of Maryland, Baltimore. The patient previously had received minimal dental care and could not recall ever having undergone professional dental prophylaxis. Her medical history was remarkable for type 2 diabetes and hypertension, which were being treated with glyburide with metformin and hydrochlorothiazide, respectively. The patient denied use of oral contraceptives or tobacco products or consumption of alcohol.
A clinical examination was significant for the conspicuous presence of diffuse, deep blue pigmentation with whitish speckling affecting the buccal and labial aspects of the maxillary gingiva (Figure 1
), abruptly arising from the right first premolar to the left second premolar and extending from the mucogingival junction to the marginal gingiva (Figure 2). Ornate tribal tattoos adorned each forearm (Figure 3). Periodontal assessment revealed generalized mild periodontitis and the presence of calculus and bleeding on probing throughout the dentition. Pocket depths averaged 2 to 3 millimeters, with occasional 4-mm pockets (confined to the maxillary second and third molars). The posterior teeth were remarkable for moderate-to-severe bruxism, and teeth nos. 16 and 18 exhibited deep caries.
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Figure 1. Diffuse blue pigmentation, attributed to tattooing of the maxillary facial gingiva. The mandibular gingiva is unaffected and exhibits only focal areas of racial pigmentation.
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Figure 2. Well-demarcated borders of the gingival tattoo. A. Maxillary right premolar region. B. Maxillary left premolar region.
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Approximately six years before, the patient had been examined in several clinics in Ethiopia for pain in the maxillary anterior region and had received the recommendation that she undergo extraction of her anterior teeth. As the patient was opposed strongly to having her teeth extracted, she requested the help of a local villager in Ethiopia who provided traditional homeopathic treatment for oral pain, involving gingival tattooing. The patient described the tattooing technique, in which the unanesthetized gingiva was pierced repeatedly with a needle tipped with a mixture of lantern soot and resin from the leaves of the plant Datura stramonium. This painful process lasted for about 30 minutes and concluded when the gingiva had bled "red." Other than the immediate discomfort during the tattooing, the patient indicated that the treatment had had no adverse effects. The patient explained that the tattoo had been extended bilaterally to the maxillary premolar regions for fear that, otherwise, the pain would be transmitted "all across the front." The intraoral tattooing, however, did not alleviate her oral pain.
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DISCUSSION
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Datura stramonium, a member of the Solanaceae (nightshade or potato) family, is an annual weed found in agricultural areas and disturbed soils throughout most of the world. Common appellations include "jimsonweed," "thorn apple," "stinkweed," "angel’s trumpet" and "devil’s trumpet." The leaves, prickly seedpods, flowers and stems possess varying concentrations of pharmacologically active tropane alkaloids, such as atropine, hyoscyamine and scopolamine. Intake of these compounds can invoke anticholinergic responses from the central and peripheral nervous systems, potentially leading to myriad systemic illnesses, hallucinations or even death.17
Widespread ethnobotanical use of D. stramonium for oral afflictions is well-documented. Datura extracts have been used for centuries in homeopathic preparations for asthma, psychosis, epilepsy, depression, burns, wounds and Parkinson disease.18,19 The utility of using extracts from the Datura plant may have some merit, as some investigators have demonstrated its antimicrobial activity in vitro.20 Furthermore, the plant apparently achieves palliation by means of a "narcotic" effect its resin produces.21 People from various cultures have treated toothaches by inhaling vapor from boiled seedpods22 or leaves,23 chewing the root,24 smoking the leaves25 and unspecified use of the flowers.26 Similarly, investigators have demonstrated that Datura metel (formerly known as Datura fastuosa) decreased pain perception and increased reaction time in laboratory mice after administration of extracts from the leaves and seeds.27 Pereira and Nishioka28 reported the adverse consequences of a patient’s use of toothpaste that consisted of tea brewed from D. stramonium leaves and flowers, salt, vinegar and an alcoholic beverage distilled from sugarcane. The patient developed symptoms of acute Datura toxicity, experiencing confusion, hallucinations, tachycardia, hypertension, dry mouth, mydriasis and dry, hot, flushed skin; the patient spontaneously recovered within 12 hours.
In some cultures, notably Ethiopian, gingival tattooing is undertaken for esthetic enhancement and occasionally for traditional tribal purposes and usually is performed in girls during the first and second decades of life.8–16 The patient in our report was atypical, as she was approximately 48 years old when she underwent the gingival tattooing and, as stated, not for cosmetic purposes. Other people subject themselves to tattooing for superstitious motives, believing the extrusion of blood after repeated pricking of the gingiva will maintain the health of their teeth.8,11 The literature describes various pigments and techniques used for gingival tattooing, including an unspecified blue and black dye tattooed with needle sticks (plant derivation not mentioned),14 soot-coated thorns (plant derivation not mentioned),8,9 thorns of Balanites aegyptiaca and a mixture of charcoal and seeds of Acacia nilotica variety tomentosa as the coloring agent,16 burnt seeds and herbs combined with lantern soot and pricked with thorns (plant derivations not mentioned),15 lampblack mixed with unspecified herbs and applied with needles,15 and soot (no specific application technique cited).11,13
Our case report apparently is the first account published in the English language literature detailing the use of gingival tattooing, performed with lantern soot and the resin from the plant D. stramonium, specifically for the intent of elimination of oral pain. The gingival tattooing in the case described here ultimately proved to be unsuccessful, and the patient has been encouraged to pursue comprehensive dental care. Al-Shawaf and colleagues10 reported four cases of gingival tattooing performed for management of periodontal disease, describing the process as "blood letting as treatment for gingival congestion" involving the use of a sharp needle coated with kohl powder, a gray-black antimony sulfide compound, although the clinical outcome was not provided. Interestingly, radiographic examination of affected patients may reveal scattered, fine grains of radiopacity in the gingiva.10
There are numerous causes of oral pigmentation, the list of which is beyond the scope of this article. Briefly, physiological melanin deposition, various local and systemic disorders, medications, systemic intoxification, accidental or intentional deposition of foreign substances and some oral hygiene herbal preparations may impart discoloration to the oral epithelium.14,29 Identification of the custom of ethnobotanical tattooing of the gingiva is accomplished by means of a detailed medical history, corroboration by the patient and the presence of symmetrical pigmentation with well-demarcated borders, usually affecting only the maxillary gingiva. Histopathologic assessment of tattooed gingiva has demonstrated interstitial deposition of aggregates of black granules in the underlying connective tissue, with varying degrees of a chronic foreign-body inflammatory response.9,10,15 Ink particles found in cutaneous tattoos remain incorporated in the cytoplasm of fibroblasts, surrounded by a collagen matrix, elastic fibers and connective tissue, immobilizing the cell body and effectively stabilizing the pigment.30 Biopsy of gingival tattoos usually is not necessary and is reserved for anomalous clinical presentations, such as suspected cases of melanoma and Kaposi sarcoma.
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CONCLUSION
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This case report details the unsuccessful administration of gingival tattooing, an Ethiopian ethnobotanical remedy for oral pain. The regimen consisted of piercing the gingiva with a needle coated with a mixture of lantern soot and the resin from the plant D. stramonium, a process that subsequently induced blue pigmentation. Clinicians should include in their differential diagnoses the practice of oral tattooing when unusual, bilateral and well-defined areas of pigmentation are observed.
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FOOTNOTES
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Dr. Brooks is a clinical professor, Department of Diagnostic Sciences and Pathology, Baltimore College of Dental Surgery, Dental School, University of Maryland, Baltimore, 650 W. Baltimore St., Baltimore, Md. 21201-1586, e-mail "oralpath5{at}comcast.net". Address reprint requests to Dr. Brooks.
Dr. Reynolds is a professor and the chair. Department of Periodontics, Baltimore College of Dental Surgery, Dental School, University of Maryland, Baltimore.
The authors would like to thank Lynn Bohs, PhD, University of Utah, for taxonomic identification of the Datura stramonium plant used for the gingival tattooing and Dr. Kyong S. Choe, Department of Periodontics, Baltimore College of Dental Surgery, Dental School, University of Maryland, Baltimore, for his photographic expertise.
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REFERENCES
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