Manas Dave discusses a topic featured in our sister journal Evidence-Based Dentistry.

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‘Oral complications associated with the piercing of oral and perioral tissues and the corresponding degree of awareness among public and professionals: A systematic review' was published in the journal Diagnostics (Basel) in November 2023.1 An evidence-based summary of this article, ‘Oral piercings: what implications do these have on our oral health?' was published in Evidence-Based Dentistry earlier this year.2

There are numerous reports of the side effects of oral piercings such as gingival recession, tooth fracture, periodontitis and bacterial and fungal colonisation leading to local and systemic infection and inflammation.

Background

Body piercings are seen in almost every society throughout history however oral body modification has mainly been limited to the lips. Oral piercings including those involving the lips, tongue (including lingual frenum), cheeks or uvula have become popular in modern society with women twice as likely as men to have oral piercings.1,3 There are numerous reports of the side effects of oral piercings such as gingival recession, tooth fracture, periodontitis and bacterial and fungal colonisation leading to local and systemic infection and inflammation.1,3 The aim of this systematic review was to comprehensively assess the evidence and understand the side effects from oral piercings.

Methods

An electronic database search of PubMed, Scopus, Cochrane and Google Scholar was conducted until April 2023 to understand the oral health related complications associated with oral piercings. Primary research studies were included such as case-control, cohort and cross-sectional studies including adolescent and adult populations with a range of oral piercings. Only articles published in English were included. The authors excluded case reports, in vivo and in vitro research, interventional studies, correspondence, letters to the editor, conference abstracts, hypotheses and editorials.

Risk of bias for case series were assessed using a modified DELPHI technique whereas cohort, cross-sectional and case-control study bias were assessed using the Newcastle-Ottawa Scale.

Results

  • Thirty-four studies were included in this review comprising four cross-sectional, 19 case series, nine case-control and two cohort studies

  • Quality assessment for case series determined the risk of bias to be low in 14, moderate in four and high in one study. The case-control studies had good quality (n = 5) and fair quality (n = 4) reported. The two cohort studies were of fair quality. In the cross-sectional studies, there were studies of poor quality (n = 1), fair quality (n = 1) and good quality (n = 2)

  • The authors reported outcome variability prevented them undertaking a meta-analysis.

The selected key findings of this study are:

  • Public/professional awareness: 46.8% (from 387 individuals with oral piercings) did not know of the risks of oral piercings. Most dentists (73.6% of 200 dentists surveyed) stated their recommendations on oral piercings varied and they obtained information empirically (they were not fully aware of the side effects of oral piercings)

  • Periodontal/peri-implant complications: Patients with tongue piercings (n = 48) had significantly higher plaque index around their implants, gingival index, probing depth and crestal bone loss compared to patients without a tongue piercing (n = 49). Another study demonstrated that patients with tongue piercings suffered from worse missing and filled teeth, periodontal probing depth, bleeding on probing and recession. In addition, a higher prevalence of tooth enamel cracks and scratches were observed in the piercing group. Patients with piercings were 11 times more likely to have gingival recession in the anterior lingual mandibular region compared to those without piercings

  • Microbiological analyses: 50 participants had samples taken from their piercing surface, periodontal pocket and tongue for 11 periodontal pathogenic bacteria. The results showed a significant relationship between the piercing surface and bacteria found in the periodontal pocket. Furthermore, the longer a piercing had been in place, the more noticeable the shift from bacteria with a moderate periodontopathic potential to microorganisms with a high periodontopathic potential occurred. Another study undertaken on young patients who had just pierced their tongue showed tongue piercings were likely to have Candida overgrowth compared to those with face piercings

  • Hard and soft tissue complications: Patients with tongue piercings were more likely to acquire enamel fissures, enamel fractures and lingual recessions. Another study showed the pierced side mucosa to have a higher prevalence of gingival recession.

Conclusions

The authors stated:

‘…The severity of piercing complications is related to the location of the piercing inside the oral cavity. Piercing can be one of the causes of tooth cracks and buccal depression in teeth that are in direct contact with the piercing. Analysis was significantly high in both types of lip and tongue piercings…'

Commentary

This systematic review highlighted the numerous side effects of oral piercings. The authors excluded case reports however they were still unable to undertake a meta-analysis due to the heterogeneity of included studies. Whilst the evidence exists of the side effects of oral piercings, more research is needed to provide the high-quality evidence needed to inform clinical guidelines.