Introduction

An increasing number of patients are presenting to their dentists wearing jewellery inserted into the peri-oral and intra-oral tissues.1 Peri-oral piercing sites include the lips and cheeks, while intra-oral piercing is generally confined to the tongue. A conventional tongue piercing is usually sited in the midline, just anterior to the lingual frenum in the sagittal plane.

Tongue piercing was first reported in the medical literature by Scully and Chen2 in 1992. Since then there have been numerous case reports documenting a variety of complications associated with the procedure. The complications reported are diverse and range from potentially life-threatening conditions, for example, airway obstruction,3,4,5 prolonged bleeding6,7,8 and infective endocarditis,9,10,11,12 to traumatic injury to the teeth and periodontal tissues from the intra-oral jewellery.13,14,15,16,17,18,19,20,21 Since the literature is mainly confined to individual cases or small series of patients, it is difficult to accurately assess the magnitude of the risks facing individuals undergoing tongue piercing. A recent survey of students in the United States (US), who had any part of their body pierced, indicated that 17% had experienced complications which required medical advice.22 This suggests that the prevalence of complications associated with tongue piercing could be significant and may represent an important public health issue in the United Kingdom (UK) as well as the US.

To date, there have only been two population studies that have focussed on individuals with tongue piercings, both of which were based in the US. Boardman and Smith13 surveyed 51 individuals with tongue piercings from establishments in San Francisco and found that 25% had experienced tooth damage as a consequence of wearing tongue jewellery. Two subjects also reported that they had required medical or dental treatment following piercing. Another research group in California examined the mouths of 52 individuals and found that tongue piercing was associated with an increased risk of damage to the teeth and gingivae.18

Little is known about the prevalence of complications following tongue piercing in the UK. There is also a paucity of information about the individuals who provide tongue piercing and the environment in which they work. Currently in the UK, only the local authorities in London have powers to regulate the practice of body piercing [The London Local Authorities Act 1991 and the Greater London Council (General Powers) Act 1981]. Local authorities outside London have the provision to regulate ear piercing [Local Government (Miscellaneous Provisions) Act 1982], but not body piercing per se. Following the death of a teenager in Sheffield, as a consequence of a lip piercing, the City Council introduced a voluntary code of practice for body piercers. The Member of Parliament for Heeley, Sheffield, also tabled a debate in the House of Commons on body piercing.23 In response, the Parliamentary Under-Secretary for Health indicated that the Local Government Bill would be amended to enable all local authorities in England to regulate the practice of body piercing. Regulation is likely to include licensing for all piercers and the introduction of byelaws to ensure a safe environment for individuals seeking any form of body piercing.

The aim of this study was to investigate reported complications following tongue piercing in a population sampled from an area where piercers are not currently regulated or subject to a voluntary code of practice. The attitudes of body piercers, working in a non-regulated area, towards control of cross-infection and the prevention of complications following piercing, were also examined.

Methods

The study was divided into two parts: a questionnaire study of subjects with a tongue piercing ('piercees') and an interview-survey of subjects who practise tongue piercing ('piercers') in two major cities (Bristol and Bath) in the South West of England. The South West Local Research Ethics Committee (United Bristol Healthcare Trust) gave approval for the study.

Survey of piercees

A self-administered questionnaire was developed by the research team to examine the following issues: age at piercing; reported problems experienced by piercees following piercing; sources of help for piercees who experienced a problem; and piercees' expectations of problems following tongue piercing. Subjects were included in the study if they had a tongue piercing and were over the age of 18 years old. In order to limit recall bias, only those individuals who had undergone tongue piercing within the last five years were included in the survey. The questionnaire was piloted using clients attending a piercing centre in Bristol.

Following the pilot study, the items in the questionnaire which related to problems and complications following tongue piercing were divided into three defined time frames: problems which occurred within the first 24 hours; problems occurring within the first week and problems experienced more than a week after piercing. The final questionnaire covered 28 items relating to tongue piercing.

The plan for the study was to recruit piercees from piercing establishments in the Bristol and Bath area. These establishments were identified from local telephone directories and a search of the Internet. Permission was sought from the managers of these establishments for two members of the research team (LRS and JVW) to visit and invite their clients to take part in the survey. The aims of the survey were explained to potential participants by the researchers who stressed that the data collected would be confidential and anonymised.

Although the researchers visited two establishments a total of 10 times over a one week period, the number of individuals recruited by this method was very low (n = 6). This reflected the small number of individuals requesting tongue piercing at these establishments during this period. Consequently, it was agreed to increase the sampling frame to include subjects attending social events taking place in the South West of England where piercees are known to congregate.

The same two researchers (LRS and JVW) attended four events over a four week period in the summer of 2003 (three music events at Public Houses in Bristol; The Eclipse, The Hatchet, The Mandrake and The Carling Weekend: Reading Festival, Reading). These locations were selected on the presumption that there would be individuals with body piercings in attendance. Such individuals were approached by the two researchers and invited to take part in the survey. Those who agreed and who met the inclusion criteria for the study were informed of the aims of the survey and asked to give their consent to take part. Subjects who consented to take part in the study were given a copy of the questionnaire to complete. The researchers were available to explain any questions that were unclear or ambiguous. Once the subject had completed the questionnaire they were asked to place it in an envelope, which was then sealed and collected by the research team.

The completed questionnaires were coded by the research team. In the situation where an individual had indicated a problem lasting more than one time frame, the longest duration was recorded. The data were entered into a spreadsheet in Microsoft Excel (Microsoft, USA) for analysis.

Survey of piercers

A second questionnaire was designed to assess the environment in which tongue piercings are provided and the attitudes of piercers towards informing clients about potential complications. The questionnaire covered 23 items relating to tongue piercing including: the number and range of types of piercings undertaken; the age of clients; consent procedures; medical history taking; advice given to clients following tongue piercing; the management of serious complications; and cross-infection and hygiene measures.

Piercers working in the piercing establishments in Bristol and Bath identified during the first part of the study were contacted by the researchers and invited to participate in the study. The aims of the study were explained to the potential participants and consent was obtained. It was stressed to the participants that all the data collected would be confidential and anonymised. Piercers who agreed to take part in the study were interviewed in their workplace by two members of the research team (LRS and JVW) using the questionnaire as the basis of a structured interview. Study participants were also given the opportunity to add their own comments at the end of the interview. The completed questionnaires were coded by the research team and the responses entered into a spreadsheet for analysis, as described previously.

Data analysis

Descriptive analyses were used to evaluate the responses of the study participants to the two questionnaires. The data from the two questionnaires were analysed separately.

Results

Survey of piercees Participation

One hundred and twenty six piercees met the inclusion criteria for the study and were invited to take part in the survey. Individuals were requested to complete a self-administered questionnaire and return it immediately; 123 individuals returned the completed questionnaire.

Duration of tongue piercing

The length of time that the tongue piercing had been in situ ranged from one to 60 months. The mean time that the tongue jewellery had been present was 29 months.

Age at piercing

Figure 1 shows the reported age at tongue piercing for the sample. The mean reported age for undergoing tongue piercing was 19 years old (Range 13 to 43 years). Six participants (5%) reported that they were below the age of 16 years old when they had their tongues pierced. Four were 15 years old and two were only 13 years old at the time of piercing.

Figure 1
figure 1

Reported age of individuals at tongue piercing

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Problems following tongue piercing

Almost all the piercees (n = 122; 99%) reported that they had experienced problems following their tongue piercing, particularly during the first 24 hours after the procedure. Overall, the most frequently reported problems were swelling of the tongue (98%), pain (71%), difficulty eating (66%) and speech problems (51%; Table 1). The frequency of problems following piercing reduced with time. Within the first 24 hours our sample reported a total of 381 problems; up to one week after piercing there were 202; after one week 174 were reported. Therefore, just over half of all the problems following tongue piercing were experienced within the first 24 hours.

Table 1 The most frequently reported problems following tongue piercing
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The nature of the problems experienced by our sample also changed with time (Table 1). The problems most commonly reported during the first 24 hours following piercing were swelling of the tongue (54%), pain (54%), bleeding (41%) and difficulty eating (34%). One individual reported that they had difficulty breathing during this time and had sought help at an Accident and Emergency (A&E) department. Up to one week after piercing similar problems were experienced; the most frequently reported problem was a swollen tongue (36%). Participants also indicated that they had difficulty eating (29%), speech problems (19%) and pain (15%) during this time. After the first week following piercing the nature of the problems experienced by participants changed. The most common complications reported were ingestion of the jewellery (29%), tooth fracture (28%), plaque and calculus deposits on the jewellery (26%) and enlargement of the piercing hole (12%). Seven individuals (6%) also reported that they had 'inhaled' jewellery; fortunately, all reported that they had successfully expelled this by coughing.

Sources of help following complications

Sixteen participants (13%) reported that they had sought advice about a problem following their tongue piercing. Nine individuals initially sought help from the piercer and eight consulted a healthcare professional. Of the latter group, four went to a general medical practitioner, two attended a hospital A&E department and two visited their dentist.

Expectations of problems following piercing

To examine piercees' expectations of problems following piercing, participants in the survey were asked to respond to two statements regarding their piercing: 'The problems I'm experiencing are exactly as I expected, given the warnings I've been given' and 'I'm coping well and I'm confident it's only a temporary situation'. The majority of respondents (n = 105; 85%) agreed with the first statement while 72% (n = 89) agreed with the second statement. A small number of participants disagreed with these statements (n = 4 and n = 5 respectively). These data suggest that most of the piercees in our survey felt well informed about what to expect following their tongue piercing.

Survey of piercers Participation

The managers of 63 piercing establishments identified in the Bristol and Bath area were contacted by telephone. Over half (n = 34; 54%) did not pierce tongues and seven (11%) did not wish to take part in the survey. A total of 22 piercers, representing 22 piercing establishments, agreed to be interviewed.

Age of piercees and consent

The majority of piercers (n = 15; 68%) reported that their minimum age requirement for tongue piercing was 16 years old; two piercers required their clients to be at least 18 years old. Five of the piercers interviewed indicated that they would be prepared to carry out a tongue piercing for an individual younger than 16 years of age as long as parental permission was sought. Of the latter group, two piercers had no specific age restriction and the remaining three indicated minimum ages of 12, 13 and 15 years old respectively. All the piercers reported that they asked clients their age before piercing. Piercers estimated that most individuals requesting a tongue piercing were between the ages of 16 and 25 years old.

Medical history

The majority (n = 19; 86%) of the piercers in this study reported that they enquired about the health of their clients prior to piercing. The range of questions asked about client health was diverse. Most piercers specifically asked about epilepsy (n = 11; 50%), human immunodeficiency virus (HIV) and hepatitis virus status (n = 9, 41%), diabetes (n = 8, 36%), heart disease and hypertension (n = 8, 36%), and bleeding disorders (n = 8, 36%). Interestingly, only one piercer routinely asked their clients whether they had a history of heart valve disease or other conditions that would put them at increased risk of developing bacterial endocarditis following tongue piercing.

Advice following tongue piercing

All the piercers interviewed said that they gave advice to their clients about how to reduce complications following tongue piercing. With the exception of one piercer, verbal advice was supplemented with written information. The most common advice given was the use of a proprietary or salt-water mouthwash after piercing (n = 22, 100%). The majority of piercers (n = 20; 91%) also warned clients about the risk of tongue swelling. Seven (32%) respondents reported that they advised clients about the risk of wound infection and six (27%) specifically warned about the risk of damage to the teeth from the intra-oral jewellery. None of the piercers interviewed said that they offered any specific advice to clients regarding the control of bleeding from the piercing site.

Piercers were asked: 'Do clients ever return for advice after having a tongue piercing?' Four reported that clients returned frequently; 13 indicated that their clients occasionally returned; while five said it was rare for clients to return with problems after tongue piercing. One piercer routinely offered clients a review appointment following tongue piercing.

When piercers were asked about the advice they would give to a client who returned with a serious problem, for example, difficulty breathing or uncontrolled bleeding, the majority (n = 16; 73%) said that they would advise their client to attend the local A&E department. Three suggested that the client should contact their general medical practitioner and two indicated that they would initially manage the problem themselves. One piercer did not wish to respond.

Cross-infection and hygiene measures

In the final part of the interview piercers were asked to describe the cross-infection and hygiene measures used in their piercing establishments. Figure 2 shows the range and frequency of precautions described. All the piercers reported that they used an autoclave to sterilise their instruments. The majority of respondents (n = 18; 82%) also mentioned the use of disposable needles and half (n = 11) indicated that they routinely wore latex gloves while piercing.

Figure 2
figure 2

Cross-infection and hygiene measures described by piercers

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Discussion

This questionnaire-based survey of individuals who have undergone tongue piercing suggests that problems following the procedure are a common occurrence. The majority of problems reported, however, were minor and most of the participants felt that they had been sufficiently warned by their piercer about what to expect following their piercing. Although the majority of piercers interviewed in this survey appear to have adequate cross-infection procedures in place, knowledge of serious medical conditions such as heart valve disease, which may place an individual in grave danger following a tongue piercing, vary widely. In addition, piercers rely on the National Health Service (NHS) to provide assistance for clients in the event of a serious complication.

This study also shows that although most piercees said they were aged 18 years or over at the time of piercing, some adolescents younger than 16 years of age have received tongue piercings. While the majority of piercers in this survey did not condone the piercing of under-age clients, five admitted that they were willing to pierce minors, albeit with parental consent. Interestingly, there is no specific legislation preventing a minor having a tongue piercing. By contrast, tattooing, which carries similar risks, is controlled by the Tattooing of Minors Act 1969. Consent for tongue piercing is governed by common law, therefore, an individual under the age of 16 years may be deemed capable of giving valid consent if they are considered mature enough to understand the nature of the procedure. In London, local authorities that have powers to regulate the practice of body piercing through licensing and byelaws, recommend that piercing should not be carried out on children without parental consent. A recently proposed amendment to the Local Government Bill would extend these powers to enable all local authorities in England to regulate body piercing.23

The nature of complications reported by our sample following tongue piercing changed with time. The most common problems described during the first 24 hours after piercing were pain and swelling of the tongue. These symptoms are commensurate with the piercing procedure, reflecting local tissue damage and ensuing inflammation. Bleeding during the first 24 hours was also commonly reported. Since this was a retrospective survey, it was not possible to ascertain the severity or precise duration of bleeding in these latter cases. Significantly, none of the piercers interviewed offered any specific advice with regard to the control of bleeding from the piercing site. Hardee et al.6 reported an episode of excessive blood loss following tongue piercing and recommended that piercees are given written information about the management of bleeding, in addition to advice regarding the treatment of pain and swelling. None of the piercers in our sample appeared to be following this recommendation.

Complications experienced more than one week after piercing were predominantly related to the presence of the jewellery rather than a consequence of tissue injury per se. The commonest problems were ingestion of the jewellery, tooth fracture and deposition of plaque and calculus on the jewellery. To our knowledge, no adverse events following the ingestion of tongue jewellery have been reported in the medical literature. However, some of our subjects reported 'inhaling' a loose piece of jewellery, which could have serious consequences. Tooth fracture was reported by 28% of individuals in this survey. This concurs with the findings of Boardman and Smith13 who reported tooth fracture rates of 25% in their study. Furthermore, Campbell et al.18 have demonstrated a positive correlation between the length of the barbell and trauma to posterior teeth. Anecdotally, piercees report habits such as assembling jewellery with the aid of the anterior teeth and 'clacking' the jewellery against the palatal and lingual surfaces of the teeth. Plaque and calculus deposits on intra-oral jewellery have been documented previously but are not known to have any specific long-term consequences.13,24

Most piercers indicated that if a serious problem arose as a consequence of piercing that their client would be advised to attend an A&E department. The potential burden of piercing to the NHS, therefore, could be significant, although in the present study only 7% of the piercees reported that they sought the advice of a healthcare professional following tongue piercing. An acute problem as a consequence of tongue piercing may require removal of the jewellery. However, it has been reported that the majority of A&E staff do not know how to remove the common types of tongue jewellery.25 This could lead to further unnecessary tissue trauma and anxiety for the patient.

The cross-infection measures reported by the piercers in our study were commendable. For example, all the piercers interviewed reported the use of autoclaves for multi-use items and most said they use disposable needles. The fact that piercers use similar cross-infection control techniques to healthcare professionals is reassuring and may reflect the public's awareness of blood-borne diseases, for example HIV. Nevertheless, appropriate legislation would help to ensure uniform practice by all those providing a body piercing service.

By contrast, the questions that the piercers asked their clients in order to establish whether they were fit to undergo a piercing procedure give cause for concern. Only one piercer was aware that some individuals are at risk of bacterial endocarditis following piercing. This is despite there being at least four case reports in the medical literature documenting episodes of infective endocarditis following tongue piercing9,10,11,12 and one reported death in the UK following a lip piercing.23 A recent survey of US cardiologists26 revealed that most recommend that patients with congenital heart disease avoid body piercings and that antibiotic cover should be provided prior to such a procedure. However, not all cardiac patients, particularly younger patients, may be aware that they are at risk. Ideally, piercers should systematically review their clients' medical history before piercing and make informed decisions about the safety of the procedure. Such recommendations would require piercers to undertake appropriate training. Proposed changes to legislation may help to address this issue. The present survey suggests that this is required urgently to prevent further fatalities.

The results from the survey of individuals with tongue piercings should be viewed with caution for the following reasons: 1) the recruitment of individuals for the study was not ideal and prone to sampling bias, 2) the information was gathered using a self-administered questionnaire, 3) the time since piercing in our sample varied widely (one to 60 months), which means that our data are subject to recall bias. Nevertheless, the results of the present survey are similar to those of previous studies in the US,13,18 which lends supports to the validity of our findings. When considering the data gathered from the piercers it is important to recognise that, although anonymity and confidentiality was stressed, piercers may have been suspicious of our motives and reluctant to take part. Since no data were available on the piercers who declined to take part in the study, it is difficult to establish the direction of any bias introduced into this part of the study.

Conclusion

Most individuals experience problems such as pain and swelling in the first 24 hours following the tongue piercing procedure, however, only a minority require the advice of a healthcare professional. Over a quarter of the piercees report tooth damage as a long-term consequence of their piercing. Although most piercers report that they have adequate cross-infection controls in place, few are aware of the risk of bacterial endocarditis to vulnerable individuals. Piercers also tend to rely on the NHS to manage serious complications when they arise. The proposed regulation of body piercing, by amendments to the Local Government Bill, would help to protect the public by ensuring a uniformly safe piercing environment nationwide.