64
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
JANUARY, 1976
Changing Attitudes Toward Orofacial Tattoos CLIFTON 0. DUMMETT, D.D.S., Professor and Chairman, Department of Community Dentistry, University ofSouthern California School of Dentistry, Los Angeles, California
IGMENTATION of the skin and oral tissues can be artificially produced by local methods.1-3 One way in which this induced pigmentation of the skin can be achieved is by tattooing. This form of tissue coloration represents a practice dating back to 4000 B. C. Tattoos have been detected on the bodies of Egyptian mummies. Archaeologists, anthropologists and historians have traced the custom and indicated that it spread to Greece, Persia, the Sudan, China, Japan and the Polynesian Islands. In these Islands, the practice was developed to formidable artistic heights and was referred to as 'tatua' (artistic), from which the more common word 'tattoo' was derived.4 Tattoo marks are produced when insoluble coloring substances are introduced into the human skin in special artistic designs and likenesses of various characters. The indelible markings may be single or multiple, monochromatic or multicolored, may be arranged in a symmetrical or haphazard fashion, and most frequently are located on the arms, legs, fingers, chest, abdomen or back. In the mechanical procedure, needles or sharp points are used to puncture the skin into which coloring substances are introduced. The most common coloring compounds are indigo, India ink, carmine and vermilion. Infection of tissues from the use of nonsterilized points and the formation of keloids are hazards of this practice. INCIDENCE
Tattooing is performed on both sexes and on all portions of the human anatomy accessible to the needle or point. Apparently it is done for a variety of reasons including adorn-
ment, symbols of virility or patriotism, recording objects of erotic affection, or fidelity to parents, relatives and friends. The habit was formerly reputed to hold religious, magical, punitive and social significance. Perry5 emphasized group conformity pressures and ostentatious potentialities of the tattoo as being strong motivating forces conducive to the practice. Obscene, odd and unusually spectacular qualities of tattoos stimulate attractions and satisfy exhibitionistic needs, masochistic drives and abnormal desires for attention. In a 1958 study of 433 male patients at Oklahoma City Veterans Administration Hospital, Yamamoto et a16 found 65 with tattoos. The highest incidence was found on the tuberculosis services. The study pointed out that the tattooed man is not any more likely to be a psychiatric patient than a general medical or surgical one, nor is he likely to be affected with venereal disease. Nevertheless, he did show definite personality characteristics which were dissimilar to those of his contemporaries. The data indicated that the tattooed man was more impulsive, more inclined to have heterosexual adjustment difficulties, and more likely to be a disciplinary problem or to acquire a medical disability as a military serviceman. In another more recent study on inmates of a federal correctional institution, Hamburger and Lacovara7 found that of 500 inmates, 34.8% did not have any tattoos. The remaining 65.2% had one or more markings on their bodies. The most frequently tattooed areas were the arm, forearm and hand. Psychiatrists now indicate that tattooing represents the response to an urge to modify the natural state directly, similar to pricking and enlarging the lips or filing, capping and
Vol. 68, No. 1
Orofacial Tattoos
removing sound teeth. They describe it as a more primitive form of directly and indirectly modifying one's own body.4 Tattooing is also accomplished for cosmetological purposes in the treatment of some of the pigmentary dermatoses. For instance, gold salts have been tattooed into the achromic patches of vitiligo, and pigments have been tattooed in the skin defects of the face or body in treating nevus flammeus nuchae. Under such conditions, tattooing would most probably qualify as a form of health service with dermatologic and psychosocial dimensions. Tattooing is a worldwide practice among people of all stations and races, sometimes falling into disrepute, and then suddenly enjoying periods of resurgence. In the first part of this century, tattooing became generally unpopular. Because it was associated with alcoholism and the use of drugs, the practice was frowned upon by most elements in American society. However, the 1970s have seen a resurgence in the United States and the practice appears to have gained a measure of respectability. This tattoo renaissance has been attributed to the late Janis Joplin, a popular vocalist who was reputed to have had a tiny rose tattooed on her breast. Following her death there was a dramatic increase in the numbers of persons frequenting tattoo parlors. The practice has somehow become associated with freedom, liberated women, and the Equal Rights Amendment. Predictively, many of the attitudes and taboos against tattoos have undergone remarkable liberalizations, and once again, some women have become receptive to the application of tattoos all over the body. So-called 'beauty spots' are now being applied sub-nasally as well as on the cheek and chin. INDUCED PIGMENTATION OF INTRAAND EXTRAORAL TISSUES
In the past there were relatively few instances in which tattooing had been accomplished on the intra- and extraoral tissues. One of the exceptions to this general rule is the practice advocated by some prostho-
65
dontists of tattooing, intraorally, specific puncture points which are inserted for the purpose of controlling vertical dimensional measurements.9 Advocates of the method suggest that the points not be positioned in mobile tissue since, on account of the greater vascularity, there would be more of a tendency toward diffusion of the dye, and instead of a point, a blot would be more likely to occur. Placing the tattoo points over solid alveolar bone is the procedure of choice since the immovable overlying tissue would maintain the discrete, refined point. In the acutal technic, the dyes used are either India ink or tantalum paste produced by mixing powdered tantalum, a noncorrosive and malleable metal, in an antiseptic solution of Listerine. Slight spreading of the initial tattoo and disappearance of the point through absorption are two frequent criticisms that have been made of the India ink dye. Proponents of the use of tantalum paste claim that it is superior to the dye in that it does not have the aforementioned disadvantages. A further asset is claimed in that the body tolerates tantalum in a manner similar to the implant metals. In marking the hinge axis, Granger10 recommends the use of red sulfide of mercury (trade names-English vermilion and cinnabar) as the tattoo material. It is mixed with alcohol to make a smooth paste. The cinnabar is a powerful germicide and prevents infection. Granger also recommends tattooing the orbital mark on the nose. For pre-extraction records, tattooed markings have also been made intraorally, and in orthodontics, tattoo marks have been advocated as a means of determining treatment progress. Extraorally, tattoo marks have been accomplished on various parts of the face. The ears, forehead, nasal bridge and cheeks are the facial areas most frequently involved. Prosthodontists have advocated the extraoral tattooing of the hinge axis center once it has been determined. In the study7 of correctional institutional tattooings, small bluish dots were found tattooed on the cheeks of a number of homosexuals. So-called time
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
marks indicating the period served in a reformatory or penal institution were found in the form of dotted tattoos on inmates' faces and hands. From time to time there have been reported unusual and bizarre tattooings in primitive tribes of Africa and Asia. These have included intraoral and extraoral markings of weird designs and occult significance. ELIMINATING TATTOOS
The removal of tattoo marks is usually unsatisfactory. A method of tattooing a 50% solution of tannic acid into superficial lesions, then rubbing with silver nitrate sticks has been suggested by Variot.10 Occasional successes have been reported in the planing and sandpapering of superficial tattoos. Surgical excision, electroexcision or cautery on small tattoos have been the most effective methods of removal. The essential point is that removal is a difficult and protracted process and should not be undertaken without the supervision of a competent physician. SUMMARY
Tattooing is a form of induced pigmentation which can be traced back as far as 4000 B.C. Needles are used to puncture the skin after which coloring substances are introduced to bring about permanent markings. The practice is performed on both sexes and all portions of the body. Intra- and extraoral tattooings are also found. There have
JANUARY, 1976
been proposed constructive usages in prosthodontics and orthodontics. The removal of tattoo marks, though unsatisfactory, has been accomplished through drugs, abrasives and surgery. LITERATURE CITED
1. DUMMETT, C. O., Physiologic Pigmentation of the Oral and Cutaneous Tissues of the Negro. J. D. R., 421-33, 1946. 2. DUMMETT, C. 0. Abnormal Color Changes in the Gingivae. Oral Surg., Oral Med., Oral Path.,
2:649, 1949. 3. DUMMETT, C. 0. Oral Pigmentation-Physiologic and Pathologic. N. Y. State D. J., 25:407, 1959. 4. FERGUSON R. and M. SHIRLEY, R. M. GRIFFITH, and E. W. STRAUS, The Psychiatric Significance of Tattoos. The Psychiatric Quarterly, 29:112-31, 1955. 5. PERRY, A. Tattoo: Secrets of a Strange Art as Practiced among the Natives of the U. S. Simon and Shuster, Inc., New York, 1933. 6. YAMAMOTO, S. and W. SEUMAN, and B. K. LESTER. The Tattooed Man. J. Nervous and Mental Dis., 136:365, 1963. 7. HAMBURGER, E. and D. J. LACOVARA. A Study of Tattoos in Inmates at a Federal Correctional Institution-Its Physical and Psychological Implications. Mil. Med., 128:1205, 1963. 8. DUMMETT, C. 0. Induced Chromatosis: The Tattoo. Quart. Nat. Dent. A., 24:49, 1966. 9. SILVERMAN, M. D. Occlusion. Mutual Pub. Co., Wash., D. C. 1962. (Vertical Dimension Measurement and Control by Tattoo Dots on the Alveolar Ridges. Chapter 2) 10. GRANGER, E. R. Practical Proc*Aures in Oral Rehabilitation. J. B. Lippincott Co., Phila. 1962. 11. ANDREWS, G. C. and A. N. DOMONKOS. Diseases of the Skin. W. B. Saunders, 5th ed. 1963, p. 667.
THE GROWING POPULATION CRISIS "The world recorded an ominous statistic in 1975. Its population reached and passed the 4 billion mark. "This means that the number of people has doubled in the past 45 years. If the present rates of growth continue, world population will double again in 35 years. "Ninety-one percent of this growth would be in the developing countries. Their total population would increase from 2.9 billion-72% of the world population-to 6.4 billion-about 81%. "The consequences of a world population that increases at the rate of nearly 2% annually are not confined to the developing countries. They affect the quality of life everywhere in an increasingly interdependent world. Food, health, education, jobs, housing, energy, natural resources, transportation, trade, the environment, recreation-nearly every facet of life is directly or indirectly touched by the needs and demands of an increasing worldwide population. But the problem is most immediate and especially critical in the poor countries. ..." "An improvement in living conditions within the less developed countries therefore requires that attention be focused on limiting the quality and availability of health services for both urban and rural populations. "The Agency for International Development (AID) assistance programs in population and health, along with those of other donors seek to help the developing countries attack these problems."
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
JANUARY, 1976
Changing Attitudes Toward Orofacial Tattoos CLIFTON 0. DUMMETT, D.D.S., Professor and Chairman, Department of Community Dentistry, University ofSouthern California School of Dentistry, Los Angeles, California
IGMENTATION of the skin and oral tissues can be artificially produced by local methods.1-3 One way in which this induced pigmentation of the skin can be achieved is by tattooing. This form of tissue coloration represents a practice dating back to 4000 B. C. Tattoos have been detected on the bodies of Egyptian mummies. Archaeologists, anthropologists and historians have traced the custom and indicated that it spread to Greece, Persia, the Sudan, China, Japan and the Polynesian Islands. In these Islands, the practice was developed to formidable artistic heights and was referred to as 'tatua' (artistic), from which the more common word 'tattoo' was derived.4 Tattoo marks are produced when insoluble coloring substances are introduced into the human skin in special artistic designs and likenesses of various characters. The indelible markings may be single or multiple, monochromatic or multicolored, may be arranged in a symmetrical or haphazard fashion, and most frequently are located on the arms, legs, fingers, chest, abdomen or back. In the mechanical procedure, needles or sharp points are used to puncture the skin into which coloring substances are introduced. The most common coloring compounds are indigo, India ink, carmine and vermilion. Infection of tissues from the use of nonsterilized points and the formation of keloids are hazards of this practice. INCIDENCE
Tattooing is performed on both sexes and on all portions of the human anatomy accessible to the needle or point. Apparently it is done for a variety of reasons including adorn-
ment, symbols of virility or patriotism, recording objects of erotic affection, or fidelity to parents, relatives and friends. The habit was formerly reputed to hold religious, magical, punitive and social significance. Perry5 emphasized group conformity pressures and ostentatious potentialities of the tattoo as being strong motivating forces conducive to the practice. Obscene, odd and unusually spectacular qualities of tattoos stimulate attractions and satisfy exhibitionistic needs, masochistic drives and abnormal desires for attention. In a 1958 study of 433 male patients at Oklahoma City Veterans Administration Hospital, Yamamoto et a16 found 65 with tattoos. The highest incidence was found on the tuberculosis services. The study pointed out that the tattooed man is not any more likely to be a psychiatric patient than a general medical or surgical one, nor is he likely to be affected with venereal disease. Nevertheless, he did show definite personality characteristics which were dissimilar to those of his contemporaries. The data indicated that the tattooed man was more impulsive, more inclined to have heterosexual adjustment difficulties, and more likely to be a disciplinary problem or to acquire a medical disability as a military serviceman. In another more recent study on inmates of a federal correctional institution, Hamburger and Lacovara7 found that of 500 inmates, 34.8% did not have any tattoos. The remaining 65.2% had one or more markings on their bodies. The most frequently tattooed areas were the arm, forearm and hand. Psychiatrists now indicate that tattooing represents the response to an urge to modify the natural state directly, similar to pricking and enlarging the lips or filing, capping and
Vol. 68, No. 1
Orofacial Tattoos
removing sound teeth. They describe it as a more primitive form of directly and indirectly modifying one's own body.4 Tattooing is also accomplished for cosmetological purposes in the treatment of some of the pigmentary dermatoses. For instance, gold salts have been tattooed into the achromic patches of vitiligo, and pigments have been tattooed in the skin defects of the face or body in treating nevus flammeus nuchae. Under such conditions, tattooing would most probably qualify as a form of health service with dermatologic and psychosocial dimensions. Tattooing is a worldwide practice among people of all stations and races, sometimes falling into disrepute, and then suddenly enjoying periods of resurgence. In the first part of this century, tattooing became generally unpopular. Because it was associated with alcoholism and the use of drugs, the practice was frowned upon by most elements in American society. However, the 1970s have seen a resurgence in the United States and the practice appears to have gained a measure of respectability. This tattoo renaissance has been attributed to the late Janis Joplin, a popular vocalist who was reputed to have had a tiny rose tattooed on her breast. Following her death there was a dramatic increase in the numbers of persons frequenting tattoo parlors. The practice has somehow become associated with freedom, liberated women, and the Equal Rights Amendment. Predictively, many of the attitudes and taboos against tattoos have undergone remarkable liberalizations, and once again, some women have become receptive to the application of tattoos all over the body. So-called 'beauty spots' are now being applied sub-nasally as well as on the cheek and chin. INDUCED PIGMENTATION OF INTRAAND EXTRAORAL TISSUES
In the past there were relatively few instances in which tattooing had been accomplished on the intra- and extraoral tissues. One of the exceptions to this general rule is the practice advocated by some prostho-
65
dontists of tattooing, intraorally, specific puncture points which are inserted for the purpose of controlling vertical dimensional measurements.9 Advocates of the method suggest that the points not be positioned in mobile tissue since, on account of the greater vascularity, there would be more of a tendency toward diffusion of the dye, and instead of a point, a blot would be more likely to occur. Placing the tattoo points over solid alveolar bone is the procedure of choice since the immovable overlying tissue would maintain the discrete, refined point. In the acutal technic, the dyes used are either India ink or tantalum paste produced by mixing powdered tantalum, a noncorrosive and malleable metal, in an antiseptic solution of Listerine. Slight spreading of the initial tattoo and disappearance of the point through absorption are two frequent criticisms that have been made of the India ink dye. Proponents of the use of tantalum paste claim that it is superior to the dye in that it does not have the aforementioned disadvantages. A further asset is claimed in that the body tolerates tantalum in a manner similar to the implant metals. In marking the hinge axis, Granger10 recommends the use of red sulfide of mercury (trade names-English vermilion and cinnabar) as the tattoo material. It is mixed with alcohol to make a smooth paste. The cinnabar is a powerful germicide and prevents infection. Granger also recommends tattooing the orbital mark on the nose. For pre-extraction records, tattooed markings have also been made intraorally, and in orthodontics, tattoo marks have been advocated as a means of determining treatment progress. Extraorally, tattoo marks have been accomplished on various parts of the face. The ears, forehead, nasal bridge and cheeks are the facial areas most frequently involved. Prosthodontists have advocated the extraoral tattooing of the hinge axis center once it has been determined. In the study7 of correctional institutional tattooings, small bluish dots were found tattooed on the cheeks of a number of homosexuals. So-called time
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
marks indicating the period served in a reformatory or penal institution were found in the form of dotted tattoos on inmates' faces and hands. From time to time there have been reported unusual and bizarre tattooings in primitive tribes of Africa and Asia. These have included intraoral and extraoral markings of weird designs and occult significance. ELIMINATING TATTOOS
The removal of tattoo marks is usually unsatisfactory. A method of tattooing a 50% solution of tannic acid into superficial lesions, then rubbing with silver nitrate sticks has been suggested by Variot.10 Occasional successes have been reported in the planing and sandpapering of superficial tattoos. Surgical excision, electroexcision or cautery on small tattoos have been the most effective methods of removal. The essential point is that removal is a difficult and protracted process and should not be undertaken without the supervision of a competent physician. SUMMARY
Tattooing is a form of induced pigmentation which can be traced back as far as 4000 B.C. Needles are used to puncture the skin after which coloring substances are introduced to bring about permanent markings. The practice is performed on both sexes and all portions of the body. Intra- and extraoral tattooings are also found. There have
JANUARY, 1976
been proposed constructive usages in prosthodontics and orthodontics. The removal of tattoo marks, though unsatisfactory, has been accomplished through drugs, abrasives and surgery. LITERATURE CITED
1. DUMMETT, C. O., Physiologic Pigmentation of the Oral and Cutaneous Tissues of the Negro. J. D. R., 421-33, 1946. 2. DUMMETT, C. 0. Abnormal Color Changes in the Gingivae. Oral Surg., Oral Med., Oral Path.,
2:649, 1949. 3. DUMMETT, C. 0. Oral Pigmentation-Physiologic and Pathologic. N. Y. State D. J., 25:407, 1959. 4. FERGUSON R. and M. SHIRLEY, R. M. GRIFFITH, and E. W. STRAUS, The Psychiatric Significance of Tattoos. The Psychiatric Quarterly, 29:112-31, 1955. 5. PERRY, A. Tattoo: Secrets of a Strange Art as Practiced among the Natives of the U. S. Simon and Shuster, Inc., New York, 1933. 6. YAMAMOTO, S. and W. SEUMAN, and B. K. LESTER. The Tattooed Man. J. Nervous and Mental Dis., 136:365, 1963. 7. HAMBURGER, E. and D. J. LACOVARA. A Study of Tattoos in Inmates at a Federal Correctional Institution-Its Physical and Psychological Implications. Mil. Med., 128:1205, 1963. 8. DUMMETT, C. 0. Induced Chromatosis: The Tattoo. Quart. Nat. Dent. A., 24:49, 1966. 9. SILVERMAN, M. D. Occlusion. Mutual Pub. Co., Wash., D. C. 1962. (Vertical Dimension Measurement and Control by Tattoo Dots on the Alveolar Ridges. Chapter 2) 10. GRANGER, E. R. Practical Proc*Aures in Oral Rehabilitation. J. B. Lippincott Co., Phila. 1962. 11. ANDREWS, G. C. and A. N. DOMONKOS. Diseases of the Skin. W. B. Saunders, 5th ed. 1963, p. 667.
THE GROWING POPULATION CRISIS "The world recorded an ominous statistic in 1975. Its population reached and passed the 4 billion mark. "This means that the number of people has doubled in the past 45 years. If the present rates of growth continue, world population will double again in 35 years. "Ninety-one percent of this growth would be in the developing countries. Their total population would increase from 2.9 billion-72% of the world population-to 6.4 billion-about 81%. "The consequences of a world population that increases at the rate of nearly 2% annually are not confined to the developing countries. They affect the quality of life everywhere in an increasingly interdependent world. Food, health, education, jobs, housing, energy, natural resources, transportation, trade, the environment, recreation-nearly every facet of life is directly or indirectly touched by the needs and demands of an increasing worldwide population. But the problem is most immediate and especially critical in the poor countries. ..." "An improvement in living conditions within the less developed countries therefore requires that attention be focused on limiting the quality and availability of health services for both urban and rural populations. "The Agency for International Development (AID) assistance programs in population and health, along with those of other donors seek to help the developing countries attack these problems."
