REVIEW ARTICLE
NL Hennequin-Hoenderdos DE Slot GA Van der Weijden
Authors’ affiliations: NL Hennequin-Hoenderdos, DE Slot and GA Van der Weijden, Department of Periodontology, Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, Amsterdam, The Netherlands Correspondence to: Nienke L. Hennequin-Hoenderdos Department of Periodontology Academic Centre for Dentistry Amsterdam (ACTA) University of Amsterdam and VU University Amsterdam Gustav Mahlerlaan 3004 1081 LA Amsterdam The Netherlands Tel.: + 31 (0) 20 5980 307/180 E-mail: [email protected]
The incidence of complications associated with lip and/or tongue piercings: a systematic review Abstract: Objective: This review determines the incidence of complications associated with lip and/or tongue piercings based on a systematic evaluation of the available literature. Material and Methods: MEDLINE–PubMed, Cochrane-CENTRAL and EMBASE databases were comprehensively searched through June 2014 to identify appropriate studies. The incidence of complications, as established by a dental professional associated with oral and peri-oral piercings, was evaluated in populations with lip and/or tongue piercings. The quality of the case–control studies was assessed using the Newcastle–Ottawa Scale. For case series studies, the risk of bias was assessed using the National Institute for Health and Clinical Excellence scale. Results: An independent screening of 1580 unique titles and abstracts revealed 15 publications that met the eligibility criteria. The incidence of gingival recessions appeared to be 50% in subjects with lip piercings and 44% in subjects with a tongue piercing. Tooth injuries were observed in 26% individuals with lip piercings and in up to 37% of individuals with tongue piercings. Subjects with a lip piercing were 4.14 times (P = 0.005) more likely to develop gingival recession than those without a lip piercing. Subjects with a tongue piercing were more likely than non-pierced subjects to experience gingival recession (relative risk (RR) 2.77; P = 0.00001) and tooth injuries (RR 2.44; P = 0.003). Conclusion: Both lip and tongue piercings are highly associated with the risk of gingival recession, and tongue piercings are also associated with tooth injuries. Key words: complications; incidence; lip piercing; oral piercing; systematic review; tongue piercing
Introduction Dates: Accepted 23 October 2014 To cite this article: Int J Dent Hygiene DOI: 10.1111/idh.12118 Hennequin-Hoenderdos NL, Slot DE, Van der Weijden GA. The incidence of complications associated with lip and/or tongue piercings: a systematic review. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
The practice of body ornamentation in the form of piercing was adopted by ancient civilizations and remains popular in the Western world as a manifestation of self-expression (1). Today, body piercing enjoys widespread popularity, especially among young people in Europe and North America (2). Many authors argue that tattoos and body piercings at present ‘are nothing more than fashion accessories’ (3, 4), whereas others assign them a deeper psychological meaning. Body piercing can be interpreted as a visible, self-produced violation of socially defined beauty standards and body boundaries, thereby arousing social provocation (5). Others have suggested that body modifications might enable traumatized individuals to more easily live through their personal experiences (6). Sweetman (7) claimed that the permanence and the pain involved in Int J Dent Hygiene |
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Hennequin-Hoenderdos et al. Incidence of complications lip/tongue piercings
addition to the considerable amount of time required for planning and after care impart a greater value to piercing than that of simple accessories. In a study that investigated the perceptions of individuals with body piercings in relation to health behaviours and values, interviewees suggested three main reasons for body piercing: aesthetics, personal preference and fitting in with the subculture (8). Oral piercings may be placed in the lips, tongue, cheeks or uvula in various combinations. Considerable information regarding body piercing is available to adolescents through the mainstream and counterculture media, including magazines and the Internet. In particular, the Internet contains extensive information regarding body piercing, including detailed personal experiences, piercing studio listings, photos and explicit descriptions. These sources of information generally neglect to provide information on health risk factors or other health-related issues (9). The incidence of various body piercing complications varies. In one study (10) conducted in 1999, approximately 70% of the subjects with a piercing had some type of complication compared with 17% in another study (11). Intra-oral and peri-oral sites are often selected for piercing, with the tongue, lips and cheeks serving as the most commonly pierced sites. Oral piercing might begin as early as adolescence and becomes more popular in college years. Oral piercing is not harmless in that it entails local and systemic risks and has been associated with early and late complications (12). Late complications are primarily topical and include abnormal tooth wear, tooth chipping, cracking and gingival recession (13). Oral piercing is associated with serious complications as infections, abscesses and endocarditis which may cause considerable post-operative discomfort and can even be life-threatening (14). Based on a summary of the available literature, HennequinHoenderdos et al. (14) concluded that the percentage of oral and peri-oral piercings is approximately 5.2% in a young adult population (varying from 0.8% to 12%). When examined based on anatomical site, the most common sites included the tongue (a prevalence of 5.6%) followed by the lip (1.5%). Oral piercings were more prevalent in women (5.6%) than in men (1.6%) (14). Gingival recession was the most frequently described complication. Periodontitis and gingival recession were observed at the central mandibular incisors. Tooth fracture was mostly reported in subjects with tongue piercings. Subjects with tooth fractures reported a habit of knocking, clacking, biting, clenching, playing, rubbing or tapping the jewellery against their teeth. Among the case reports, reported complications included normal post-operative swelling and localized inflammation as well as more serious complications that could have been life-threatening. Moreover, in the long term, piercing may be associated with gingival recession and tooth fracture. Therefore, oral and/or peri-oral piercings are not without risks, and patients considering a piercing should be made aware of this fact (13). As one direction for further research, Hennequin-Hoenderdos et al. (14) suggested that the actual incidence of complications associated with oral and/or peri-oral piercings requires further delineation. The purpose of 2
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this review was therefore to systematically assess the literature for information concerning the incidence of complications from lip and/or tongue piercings to accurately assess the magnitude of the risk faced by individuals with these piercings. Such a study should also provide relevant information for those planning to obtain an oral or peri-oral piercing and enable dental care professionals (DCPs) to properly inform and advise the population.
Materials and methods This systematic review was conducted in accordance with the Cochrane handbook (15) for systematic reviews of interventions that provides guidance for the preparations and the guidelines of Transparent Reporting of Systematic Reviews and Meta-analyses (16). Focused question
A protocol was developed a priori for the question: What is the incidence of complications associated with oral and/or perioral (lip and/or tongue) piercings? Search strategy
The search strategy was developed with in accordance with published guidance for undertaking of systematic reviews (17). Three Internet sources were used to identify papers that satisfied the study purpose: the National Library of Medicine, Washington, DC (MEDLINE–PubMed), the Cochrane Central Register of Controlled Trials (CENTRAL) and EMBASE (Excerpta Medica Database from Elsevier). The databases were searched for studies conducted through January 2015 (Box 1). Box 1. Search terms used for MEDLINE–PubMed, CochraneCENTRAL and EMBASE. The search strategy was customized appropriately for each of the additional databases used by taking into account differences in controlled vocabulary and syntax rules. The asterisk (*) was used as a truncation symbol. {[ AND ] OR [total construct]} {[ AND ] OR [(mouth piercing*) OR (oral piercing) OR (lip piercing) OR (cheek piercing) OR (buccal piercing*) OR (tongue piercing) OR (lingual piercing*) OR (frenulum piercing) OR (uvula piercing) OR (venom piercing) OR (tooth piercing*) OR (gingiva piercing) OR (gums piercing) OR (mucosa piercing)]}
Screening and selection
Two reviewers (NLHH and GAW) independently screened the papers, first by title and then by abstract. If the information relevant to the eligibility criteria was not available in the abstract or if the title was relevant but the abstract was not available, the full text of the paper was read.
Hennequin-Hoenderdos et al. Incidence of complications lip/tongue piercings
Next, full-text papers that fulfilled the eligibility criteria were identified and included in this review. The eligibility criteria were as follows: Human subjects Cross-sectional, cohort, or case–control studies or case series Oral and/or peri-oral piercings located in the lip and/or tongue Outcomes: – Complications determined by a DCP – Incidence of complications regarding gingival recessions and/or tooth injuries – Scores by absolute numbers or percentages Papers in English or Dutch Any disagreement between the two reviewers was resolved after additional discussion. If a disagreement persisted, the judgment of a third reviewer (DES) was considered to be decisive. The two reviewers (NLHH and GAW) hand-searched the reference lists of all of the selected studies for additional published papers that could possibly meet the eligibility criteria. Papers that fulfilled all of the selection criteria were processed for data extraction. Quality assessment
The studies were judged for risk of bias by two reviewers (NLHH and DES). For case series studies, the methodological study quality was assessed using a checklist for the quality appraisal of case series studies that was developed at the Institute of Health Economics (IHE) (18, 19). The checklist consisted of 20 criteria. Each study was reviewed by answering ‘yes’, ‘partial’, ‘no’ or ‘unclear’. The maximum number of ‘yes’ responses for a study is 20 because each criterion is weighted equally. Prior to the appraisal, four criteria (9, 11, 13, 16) were considered not applicable. ‘Partial’ responses were considered ‘yes’, and ‘unclear’ was considered ‘no’ for estimating the risk of bias. A study with 0–2 ‘no’ responses was considered to have a low risk of bias, 3–5 ‘no’ responses a moderate risk, 6–8 a high risk and ≥9 a very high risk of bias. The risk of bias in case–control studies was determined using the Newcastle–Ottawa Scale (NOS) (20) for assessing the quality of non-randomized studies. This scale consists of nine items that cover three categories: the selection of the study groups; the comparability of the groups; and the ascertainment of either the exposure or the outcome of interest. The descriptions of the original NOS items were adjusted by the authors (Appendix S1) to more appropriately connect to the topic addressed in the present manuscript. This adaptation of items was previously described by Taggart et al. (21).
were extracted for a descriptive summary, and the data for both the piercees and the controls were used for the risk meta-analysis. After a preliminary evaluation of the selected papers, the data were presented in a descriptive manner. First, the number and percentage of piercees with gingival recession or a tooth injury were extracted and/or calculated per study and piercing site (tongue piercing, lip piercing or tongue and lip piercings). In addition, the weighted mean percentage for gingival recessions and tooth injuries was calculated. For the case–control studies, a risk meta-analysis was performed with relative risk (RR) as the outcome measure using Review Manager (REVMAN) Computer program (version 5.1 for Windows; The Nordic Cochrane Centre, The Cochrane Collaboration, Denmark, Copenhagen). RR values between the test and control groups were calculated using a fixed-effects model and a 95% confidence interval (CI), and P-values were calculated as well. Heterogeneity was tested using the chisquare test and the I2 statistic. A chi-square test resulting in P < 0.1 was considered an indication of significant statistical heterogeneity. As a rough guide for assessing the possible magnitude of inconsistency across studies, an I2 value of 0– 40% was interpreted as non-imperative, and moderate to considerable heterogeneity was assumed to be present for values above 40%. This quantitative analysis assessed the complications of gingival recession and tooth injury.
Results Search and selection results
The searches resulted in 1864 unique papers. After screening by title and abstract, 33 papers were selected for full-text reading, of which 18 papers were excluded because they provided no information regarding the focused question and/or did not match the eligibility criteria. Reasons for exclusion are detailed in Appendix S2. The reference lists from the selected studies were searched, but no additional papers were identified. Consequently, 15 papers were selected and processed for data extraction. A schematic overview of the search and selection results is presented in Fig. 1. Table 1 presents an overview of the selected studies. Study design
Seven studies (#04, #07, #08, #09, #11, #12, #15) were case– control studies. One (#09) of these studies applied a split-mouth evaluation in which contralateral teeth served as controls. The remaining eight studies were case series studies. No cross-sectional studies were identified.
Data analysis
Regarding the focused question, data were extracted from the selected papers by the two reviewers (DES and NLHH). For case series studies, all subjects were considered. For the case– control studies, the data on the piercees (i.e. pierced subjects)
Quality assessment
The risk of bias was assessed for case series studies using the IHE checklist for the quality appraisal of case series studies (18, 19). Quality assessment values are presented in Int J Dent Hygiene |
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Cochrane-CENTRAL
PubMed-MEDLINE
EMBASE
110
1585
473
Screening
Excluded by title and abstract 1831
Unique title & abstracts 1864
Eligibility
Identification
Hennequin-Hoenderdos et al. Incidence of complications lip/tongue piercings
Excluded after full reading 18
Selected for fulltext reading 33 Included from the reference lists 0
Experiments 15
Case-controls 7
Descriptive Analyses 15
Meta Analyses 7
Case Series 8
Analyzed
Included
Included papers 15
Tongue piercings 10
Lip piercings 9
Tongue & lip piercings 3
Tongue piercings 4
Lip piercings 4
Fig. 1. Search, selection and analysis processes.
Appendix S3. Based on these criteria, the estimated potential risk of bias was low for one study (#01), moderate for two (#13, #14), high for three (#03, #06, #10) and very high for two (#02, #05) studies. The included case–control studies were classified according to the adjusted NOS (20). Five studies (#08, #09, #11, #12, #15) were considered to have a low risk of bias; two (#04, #07) had a moderate risk, and none had a high risk of bias (Appendices S4 and S5). Heterogeneity
Twelve studies (#01, #03, #04, #07, #08, #09, #10, #11, #12, #13, #14, #15) presented information concerning their procedures for clinically assessing oral complications. Three studies (#02, #05, #06) did not provide specifications in their Materials and Methods sections. 4
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Five studies (#08, #11, #13, #14, #15) reported that all measurements were obtained by the same examiner. In one study (#04), the examination was performed by a registered dental hygienist or a dental hygiene student under the supervision of a registered dental hygienist. In Pires et al. (33; #12), all examinations were performed by two trained and calibrated examiners. Inter- and intra-examiner agreements were established by re-examinations. Campbell et al. (22; #01) noted that agreement between two examiners was required for all recordings. Controlled intra-examiner consistency was established in one study (#11) by photographic remeasurement. Eight studies (#01, #03, #07, #08, #11, #12, #14, #15) used a periodontal probe to perform the dental examination. In two studies (#08, #11), gingival recession from the cement-enamel junction (CEJ) was measured with a calibrated periodontal probe. Five studies (#07, #10, #11, #13, #14) used the Miller classification (35) for scoring gingival recession. Two studies
Campbell et al. 2002 (22)
De Moor et al. 2000 (23)
De Moor et al. 2005 (24)
Dougherty & TervortBingham 2005 (25)
Ebrahim & Naidoo 2008 (26)
Garcia-Pola et al. 2008 (27)
Giuca et al. 2012 (28)
Kapferer et al. 2007 (29)
Kapferer & Beier2012 (30)
02
03
04
05
06
07
08
09
Included studies
01
Study #
Case–control study, split-mouth
Case–control study
Case–control study
Case series
Case series
Case–control study
Case series
Case series
Case series
Study design
47 Students
50 Students
50† Patients
18◊ Patients
126† Students
23 Patients
50† Patients
15 Patients
52† Young adults
# Subjects Type of subjects
Table 1. Overview of the studies processed for data extraction Type of piercing Mean wear (SD)Range of duration of wear in months Tongue 30 (24) months 1 day–108◊ months
Tongue 13.2 months Range ? Tongue and/or lip 12.6 months Range ? Tongue 40◊ months 4◊–150◊ months Tongue and/or lip Wear ? Range ? Tongue and/or lip Wear ? Range ? Tongue and/or lip 48◊ (31◊) months Range ?
Lip 39.4 (3.5) months 3–108◊ months
Lip 37.3 (33.6) months Range ?
Gender Mean age (SD) Range in years ♂ 31 ♀ 21 22 years 18–40 years
♂ ? ♀? Age ? Range ? ♂ 13 ♀37 Age ? 12–>40 years ♂ 9 ♀14 23.4 years 18–39 years ♂ 19 ♀ 107 17.46 (1.86) years 14–24 years ♂?♀? Age ? Range ? ♂ 22 ♀ 28 T: 23.4 (3.6) years C: 24.6 (3.9) years 18–34 years ♂ 6 ♀44 21.76 (2.7) years Range ?
♂ 13 ♀ 34 20.2 (4) years Range ?
Lateral lower lip piercing is associated with significantly increased plaque accumulation on the adjacent teeth. A small percentage of lateral lower lip piercings may cause tooth chipping or buccal recession in adjacent teeth
The prevalence of gingival recession is associated with labial piercing. The position of the intra-oral disc and time since piercing are associated with a greater prevalence of buccal recession
The prevalence of abnormal tooth wear and tooth chipping was higher in the subjects with labial or lingual piercings. Moreover, patients with tongue or labial piercings exhibited a higher gingival recession compared with control subjects with no oral piercings
Buccal gingival recession is related to lower lip piercing
Long-term complications included chipping of teeth and gingival recession
Individuals wearing a tongue stud for any length of time are at risk for developing abnormalities in the alveolar bone surrounding the mandibular anterior teeth
The most common dental problem registered was chipping of teeth, especially in association with tongue piercing. Gingival recession was associated with lip piercing with studs
The most common dental problem registered was chipping of teeth. Trauma of the lingual anterior gingiva was the most common gingival problem
Tongue piercing is associated with lingual recession of the mandibular anterior teeth and chipping of the posterior teeth. Long-term use of a tongue barbell increases the prevalence of these complications
Original authors conclusions
Hennequin-Hoenderdos et al. Incidence of complications lip/tongue piercings
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Kieser et al. 2005 (31)
Leichter & Monteith 2006 (32)
Pires et al. 2010 (33)
Plessas & Pepelassi 2012 (12)
Vilchez-Perez et al. 2009 (34)
Ziebolz et al. 2012 (2)
10
11
12
13
14
15
Case–control study
Case series
Case series
Case–control study
Case–control study
Case series
Study design
46† Military subjects
50 Patients
110† Clients of tattoopiercing studios
60 Students
91 Patients
43† Patients
# Subjects Type of subjects Tongue and/or lip Wear ? Range ? Lip 11.86 (16.4) months 1–86 months
♂ 3 ♀40 21 (5) year 14–34 years ♂ 39 ♀52 25.13 (3.69) years 20–43 years ♂ 27 ♀ 33 18.9 (3.9) years Range ? Tongue and/or lip 30.3 (30.9) months 1–144 months
Lip 35.4 (19.5) months Range ?
Tongue 3.8 (3.1) months 6–118 months
♂ 52 ♀ 58 21.25 (3.55) years 18–35 years
♂ 11 ♀ 39 21.3 (4.4) years Range ?
♂ 46 ♀ 0 22.2 years 19–26 years
Tongue 25 (2.8) months 1–96 months
Type of piercing Mean wear (SD)Range of duration of wear in months
Gender Mean age (SD) Range in years
A significant correlation was revealed between tongue piercings and the increased incidence of enamel fissures, enamel fractures and gingival recession
Lateral lower lip piercings enhance gingival recession and reduce the amounts of keratinized and attached gingiva. These ornaments are also associated with tooth fractures and cracks
The prevalence of dental defects is greater for tongue versus lip piercings. Gingival recession is similar for tongue and lip piercing. Longer duration of tongue and lip piercing is associated with an increased prevalence of dental defects and gingival recession
Tongue piercings were strongly associated with gingival recession in the anterior lingual mandibular region
A clear risk exists between lip piercing, labret use and gingival recession
Oral piercings are associated with localized gingival recession
Original authors conclusions
?, No information or data presented or data extraction not possible; ◊, Calculated by the authors of this systematic review; †, Subjects with multiple piercings; T, test group; C, control group.
Included studies
Study #
Table 1. (Continued)
Hennequin-Hoenderdos et al. Incidence of complications lip/tongue piercings
Hennequin-Hoenderdos et al. Incidence of complications lip/tongue piercings
The total number of subjects varied per study from 15 to 126. The ages of study subjects varied from 12 to 43 years, with an average age of 22 years. Eight studies used patient groups (#02, #03, #04, #06, #07, #10, #11, #14). Four studies used students (#05, #08, #09, #12), and one study examined only pierced subjects (#13). One study involved military personnel (#06), and one study evaluated young adults (#01).
oping gingival recessions and tooth injuries. Tooth injuries are a rather broad description that can include tooth defects, fractures, chipping, cracks, abrasion and splitting. The focus of this systematic review was to investigate the incidence of complications as assessed by a DCP. The results based on the included papers indicate that the risk ratio for gingival recession in relation to lip piercings was 4.14. The risk ratio for developing gingival recession in relation to tongue piercings was 2.77. Furthermore, the risk ratio for tooth injuries in subjects with a tongue piercing was 2.44. In other words, subjects with lip piercings are 4.14 times more likely to develop gingival recession compared with non-pierced subjects.
Data analyses
Study design
Descriptive summaries of the incidences of complications associated with tongue piercings, lip piercings and tongue and lip piercings are presented in Tables 2–4. Seven studies (#01, #03, #05, #07, #10, #13, #15) reported that some subjects had multiple piercings. Of the 351 included subjects who had a tongue piercing, a weighted mean percentage of 42% exhibited gingival recession. On average, 37% of 426 subjects experienced a tooth injury, such as chipped/cracked/broken teeth, tooth wear or fractures (Table 2). In subjects with lip piercings, an average 43% of 411 experienced gingival recession and 24% of 280 experienced tooth injuries (Table 3). Of 40 subjects who had a tongue and a lip piercing, an average 38% exhibited gingival recession (Table 4). In all studies, complications were assessed by a DCP. Table 5 presents the risk meta-analysis results from the case–control studies using fixed-effects models. For lip piercings, the RR for gingival recessions was 4.14 with a 95% CI ranging from 1.54 to 11.13 (P = 0.005). For tongue piercings, the RR was 2.77 with a 95% CI ranging from 1.99 to 3.85 (P = 0.00001). The RR for tooth injuries in subjects with a lip piercing was 1.33 with a 95% CI ranging from 0.74 to 2.41 (P = 0.34). For tongue piercing, the tooth injury RR was 2.44 with a 95% CI ranging from 1.35 to 4.41 (P = 0.003). The numbers of subjects with and without complications in the case and control groups are presented in Appendix S6.
Over the past decades, a strong movement towards evidencebased medicine has emerged. In this context, the randomized controlled trial (RCT) is generally considered to provide the greatest evidentiary value for assessing the efficacy of interventions (38). However, the focused question of this review was answered by a review of non-randomized trials. The literature search on this topic exclusively identified observational studies. Studies that attempt to calculate a risk factor generally cannot be randomized because exposing subjects to potential harmful risk factors would be unethical (39), that is randomly exposing non-pierced patients to the risks from oral ornaments for the purpose of a study. Therefore, the literature provides quantitative (observational) studies that estimate the effects of lip and/or tongue piercings as the observed intervention without using randomization to allocate subjects to comparison groups. Inconsistent nomenclature is often used to describe non-randomized study designs (40). To be clear about the study design terminology for the studies in this review, the descriptions from the Centre for Review and Dissemination (CRD) were followed. Their Guidance for Undertaking Systematic Reviews in Health Care (2009) (17) describes case–control studies as studies that ‘compare groups from the same population with (cases) and without (controls) a specific outcome of interest, to evaluate the association between exposure to an intervention and the outcome’. Case series are ‘a description of a number of cases of an intervention and the outcome (without comparison with a control group)’ (17). Based on these definitions, five case–control studies and eight case series were included.
(#08, #10) recorded dental injuries according to the Imfeld classification (36). Number, age, range and group of subjects
Discussion This study is the third and final in a series of systematic reviews regarding oral and peri-oral piercings. The previous studies summarized the potential complications of oral and peri-oral piercings from a comprehensive collection of case reports (13) and evaluated the prevalence of oral and peri-oral piercings among young adults (14). The popularity of oral piercings results in an increased number of complications; it is necessary that professionals be prepared to encounter such situations (37). The purpose of the present review was to obtain information concerning the incidence of complications related to lip and tongue piercings. This information will help to accurately assess the magnitude of the risks associated with devel-
Potential bias and confounders
Non-randomized studies are likely to have a greater potential risk of bias than randomized studies. Therefore, the results should be interpreted with caution, and more attention must be paid to the possibility of selection bias (41). For example, the included study by Dougherty & Tervort-Bingham (25) contained exposed weaknesses. The convenience sampling was from a small geographic area; the case group was selected, and the control group was ‘pulled from existing patient records’. The sample size was small. All of the above factors serve as potential limits to generalizing the results to a larger Int J Dent Hygiene |
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Table 2. Descriptive summary of the incidence of complications from tongue piercings Gingival recession
Tooth injury
Study #
Included studies
# Subjects
Number Percentage
Number
01 02 03 04 05 07 10 12 13
Campbell et al. 2002 (22) De Moor et al. 2000 (23) De Moor et al. 2005 (24) Dougherty & Tervort-Bingham 2005 (25) Ebrahim & Naidoo 2008 (26) Giuca et al. 2012 (28) Kieser et al. 2005 (31) Pires et al. 2010 (33) Plessas & Pepelassi 2012 (12)
52 15 47 22 100 25 33 60 51*
10 6 4 9 ? 5 14 48 24
19.2 40◊ 8.5◊ 40.9◊ ? 20◊ 42.4 80 47◊
10 12 25 8 13 ? 11 16 24
19.2◊ 80◊ 53.2◊ 36.4◊ 13◊ ? 33.3 26.7 47◊
15
Ziebolz et al. 2012 (2)
46
27
58.7
38
82.2
Total gingival recession Total tooth injury
351 426
Percentage
Description Chipped teeth Chipped teeth Chipped teeth Broken teeth Chipped teeth ? Worn incisors Fracture Worn, chipped and cracked teeth Cracked teeth
x 41.8◊ x 36.8◊
?, No information or data presented or data extraction not possible; ◊, Calculated by the authors of this systematic review; *, number of piercings.
Table 3. Descriptive summary of the incidence of complications from lip piercings Gingival recession
Tooth injury
Study #
Included studies
# Subjects
Number
Percentage
Number
03 06 07 08 09 10 11 13 14
De Moor et al. 2005 (24) Garcia-Pola et al. 2008 (27) Giuca et al. 2012 (28) Kapferer et al. 2007 (29) Kapferer & Beier 2012 (30) Kieser et al. 2005 (31) Leichter & Monteith 2006 (32) Plessas & Pepelassi 2012 (12) Vilchez-Perez et al. 2009 (34)
8 15 25 50 47 15 91 110* 50
5 5 2 34 4 14 62 40 11
62.5 33.3◊ 8◊ 68 8.5◊ 93.3 68.1◊ 36.4◊ 22
2 ? ? 18◊ 7◊ 3 ? 28 10
Total gingival recession Total tooth injury
411 280
Percentage 25 ? ? 36◊ 14.9◊ 20 ? 25.5◊ 20
Description Chipped teeth ? ? Chipped and cracked teeth Tooth chipping and cracks Worn incisors ? Worn, chipped and cracked teeth Fractured and cracked teeth
x 43◊ x 24.3◊
?, No information or data presented or data extraction not possible; ◊, Calculated by the authors of this systematic review; *, number of piercings.
Table 4. Descriptive summary of the incidence of complications from tongue and lip piercings Gingival recession
Tooth injury
Study #
Included studies
# Subjects
Number
Percentage
Number
Percentage
Description
05 07 10
Ebrahim & Naidoo 2008 (26) Giuca et al. 2012 (28) Kieser et al. 2005 (31)
10 25 5
2 8 5
20◊ 32◊ 100
? 2
? 40
? Worn incisors
Total gingival recession
40
x 37.5◊
?, No information or data presented or data extraction not possible; ◊, Calculated by the authors of this systematic review.
population. Additionally, multiple oral health care providers collected the data, and some variables were not clearly defined. Again, all of these factors could have resulted in bias. Estimating potential confounders illustrates the extent of heterogeneity between studies. Complications, such as gingival 8
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recession, may be caused by oral or peri-oral piercings, but the observed complication may also have another origin. In the literature, several authors considered other factors as causes of gingival recession, such as plaque-induced inflammation, toothbrush trauma, tooth alignment, orthodontic treatment, restor-
Hennequin-Hoenderdos et al. Incidence of complications lip/tongue piercings
Table 5. Risk meta-analyses of case–control studies using fixed-effects models Heterogeneity Model 95% CI
P-value
I2 (%)
P-value
4.14
1.54; 11.13
0.005
59
0.06
Fixed
1.33
0.74; 2.41
0.34
0
0.47
Dougherty & Tervort-Bingham 2005 (25) Giuca et al. 2012 (28) Pires et al. 2010 (33) Ziebolz et al. 2012 (2)
Random
2.77
1.99; 3.85
0.00001
14
0.32
Dougherty & Tervort-Bingham 2005 (25) Pires et al. 2010 (33) Ziebolz et al. 2012 (2)
Fixed
2.44
1.35; 4.41
0.003
0
0.70
Site
Complication
# Study
Included studies
Lip piercing
Gingival recession
07 08 09 11
Giuca et al. 2012 (28) Kapferer et al. 2007 (29) Kapferer & Beier 2012 (30) Leichter & Monteith 2006 (32)
Random
Tooth injury
08 09
Kapferer et al. 2007 (29) Kapferer & Beier 2012 (30)
Gingival recession
04 07 12 15
Tooth injury
04 12 15
Tongue piercing
CI, confidence Interval.
ative procedures, smoking status (29), calculus, poorly designed or poor-fitting partial dentures, fixed partial dentures, high lingual frenum (25), periodontal biotype (12, 29), height of keratinized gingiva (34) and oral health and hygiene status (2). Campbell et al. (22) measured some of the factors and reinforced the likely contribution of the mechanical action of the tongue barbell to the observed gingival damage, presumably during tongue protrusion. However, possible confounding factors, such as age, gender, duration of wear, sort/type of piercing, length/size of the piercing, location of the piercing, position of the piercing (i.e. angle; whether it protrudes from or is submerged under the soft tissue), piercing material, previous trauma, participation in contact sports and behaviour of the person in moving the piercing, could be relevant for the interpretation of this review. These data are lacking in the case–control studies. Risk meta-analysis and quality assessment
In this review, risk meta-analyses were performed to systematically combine the results of the included case–control studies to obtain a combined estimated effect. The RR was calculated, representing the ratio of the probability of an event’s occurring in the exposed group to the probability of the same event’s occurring in a non-exposed group. Risk meta-analyses of observational studies present particular challenges given the inherent biases and differences in study designs. However, these studies may help to understand the results and quality sources of variability across studies (39). Guidelines for reporting the risk meta-analysis results from observational studies (39) recommend that the ‘assessment of confounding factors, study quality and heterogeneity’ be clearly reported. The results of the quality assessment in this review were used to highlight items of methodological quality and heterogeneity that were addressed by the included studies. Many instru-
ments for assessing the methodological quality of non-randomized intervention studies have been created and were reviewed systematically by Deeks et al. (42). The Newcastle– Ottawa Scale (20) was developed to assess the quality of nonrandomized studies with its design, content and ease of use directed to the task of incorporating the quality assessments in the interpretation of risk meta-analysis results. A star system is used to allow for the visual, semi-quantitative assessment of study quality (42). Appendix S5 indicates the scale allowed for discrimination between case–control studies with respect to quality. The risk meta-analysis for gingival recession included low- to high-quality studies, whereas the quality in relation to tooth injuries was higher. Risk meta-analysis using the chisquare test revealed that heterogeneity was not significant in those studies that reported on tooth injuries. In the studies that reported on gingival recession, the I2 varied from 14% to 52%, which can be interpreted as minor to moderate heterogeneity. Questionnaires
Differences in research methodology (questionnaires versus clinical examination) were reflected in the different incidences of complications. The information about the variables that was presented in the selected studies was collected through clinical examination. Gingival recession reported on a questionnaire is subject to the underestimation of current conditions. Therefore, this review exclusively included studies for which complications were assessed by a DCP. Self-assessment questionnaires on non-painful gingival or dental trauma are of limited value because such damage often goes unnoticed by patients due to lack of dysfunction (29). Four studies (43–46) that were not included in this review evaluated piercees’ perceptions of the risk of complications from oral and peri-oral piercings. The results of the surveys were widespread, and it Int J Dent Hygiene |
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can be assumed that this is a reflection of the fact that questionnaires were used. Tooth injuries were reported in 3% (44) to 41% (45) of subjects, and gingival recession reporting ranged from 2% (45) to 42% (44); the values for both conditions were dependent on the piercing location. Another recently published study (47) assessed the prevalence of gingival recession among young Greek adults in a sample of 1430 subjects. In this study, the prevalence of gingival recession was found to be 63.9% as assessed by clinical examination by a periodontist. The prevalence of oral piercings was 8% as established based on a questionnaire. The authors found a weak but positive association between the occurrence of gingival recession and the presence of oral piercing. They concluded that oral piercing is a cultural-causative associating factor for gingival recession (47).
informed that the longer the duration of wear, the greater the chance that oral complications will develop. In addition, patients should be advised that piercings increase the possibility of developing dental defects and gingival recession. It is also recommended that questions regarding (former) piercings and their complications be included in medical and dental questionnaires. Practical limitation
When patients remove their lip or tongue piercings before dental examination, the DCP is unaware of the fact that these piercings could be the reason for the observed oral complications. Lip and tongue piercings as aetiological factors should be considered in the differential diagnosis of gingival recession and tooth injuries, especially in young adults.
Conclusions Within the limitations of this study, the following conclusions can be drawn. The frequency of post-piercing complications depends on piercing location in relation to the oral cavity. Piercing may cause tooth chipping or cracks as well as buccal recession in the teeth that are in direct contact with the stud closure. A significant relative risk was revealed between tongue piercings and an increased incidence of enamel fissures, enamel fractures and gingival recessions (especially in the lingual region of the mandibular incisors). Both lip and tongue piercings were highly associated with gingival recession. From the dental perspective, the popularity of oral and peri-oral piercings is a cause for concern in light of the number of oral complications and risks.
Clinical relevance Scientific rationale for the study
Gingival recessions are frequently described as a complication associated with lip or tongue piercings, and tooth fractures are reported as a complication for tongue piercings. The incidence of these complications associated with lip and tongue piercings is unknown. Principle findings
Lip and tongue piercings are highly associated with the risk of gingival recession and tooth injuries. Practical implications
Lip and tongue piercings are not without risks. Dental care professionals (DCPs) should be aware of the risks to properly inform and advise the target population. It is best to discourage oral piercings and improve awareness of the complications associated with oral piercings. Patients with these piercings should be screened by a DCP for possible dental or periodontal complications on a regular basis. The patient should be 10
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Acknowledgements The authors thank the Ivoren Kruis (Ivory Cross, the Dutch society for the promotion of dental and oral health) for initiating and partly sponsoring this project. The authors also acknowledge the support of Joost Bouwman, head librarian of the ACTA, who helped retrieve the full-text papers.
Conflict of interest The authors declare that they have no conflict of interests.
Source of funding The preparation of this review was self-funded by the authors and their institutions and supported by a seed grant from the Dutch organization that promotes oral and dental health (Ivory Cross).
References *Studies included from the search and selection process for this review. 1 Pejcic A, Kojovic D, Mirkovic D. Oral piercing and its complications in two Serbian youths: a case report and review of the literature. West Indian Med J 2012; 61: 838–843. 2 *Ziebolz D, Hildebrand A, Proff P, Rinke S, Hornecker E, Mausberg RF. Long-term effects of tongue piercing–a case control study. Clin Oral Investig 2012; 16: 231–237. 3 Craik J. The Face of Fashion: Cultural Studies in Fashion. London: Routledge; 1994. 4 Turner BS. The possibilities of primitiveness: towards a sociology of body marks in cool societies. Body Society 1999; 5: 39–50. 5 Stirn A. Body piercing: medical consequences and psychological motivations. Lancet 2003; 5: 1205–1215. 6 Wohlrab S, Stahl J, Kappeler PM. Modifying the body: motivations for getting tattooed and pierced. Body Image 2007; 4: 87–95. 7 Sweetman P. Anchoring the (postmodern) self? Body modification, fashion and identity. Body Soc 1999; 5: 51–76.
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8 Randall JA, Sheffield D. Just a personal thing? A qualitative account of health behaviours and values associated with body piercing. Perspect Public Health 2013; 133: 110–115. 9 Muldoon KA. Body piercing in adolescents. J Pediatr Health Care 1997; 11: 298–301. 10 Greif J, Hewitt W, Armstrong ML. Tattooing and body piercing. Body art practices among college students. Clin Nurs Res 1999; 8: 368–385. 11 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: 29–34. 12 *Plessas A, Pepelassi E. Dental and periodontal complications of lip and tongue piercing: prevalence and influencing factors. Aust Dent J 2012; 57: 71–78. 13 Hennequin-Hoenderdos NL, Slot DE, Van der Weijden GA. Complications of oral and peri-oral piercings: a summary of case reports. Int J Dent Hyg 2011; 9: 101–109. 14 Hennequin-Hoenderdos NL, Slot DE, Van der Weijden GA. The prevalence of oral and peri-oral piercings in young adults: a systematic review. Int J Dent Hyg 2012; 10: 223–228. 15 Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.2 [updated September 2009]. The Cochrane Collaboration; 2009. Available at: www.cochrane-handbook.org (assessed on 14 August 2014). 16 Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta analyses: the PRISMA statement. J Clin Epidemiol 2009; 62: 1006–1012. 17 Centre for Reviews and Dissemination. Systematic Review: CRD’s Guidance for Undertaking Reviews in Health Care. York: University of York; 2009. 18 Moga C, Guo B, Schopflocher D, Harstall C. Development of a Quality Appraisal Tool for Case Series Studies Using a Modified Delphi Technique. Edmonton AB: Institute of Health Economics; 2012. Available at: http://www.ihe.ca/publications/library/2012-publications/development-of-a-quality-appraisal-tool-for-case-series-studiesusing-a-modified-delphi-technique/ (accessed 14 August 2014). 19 Moga C, Guo B, Schopflocher D, Harstall C. Development of a Quality Appraisal Tool for Case Series Studies. Poster session presented at: 21st Cochrane Colloquium; 2013, 19–23 September; Quebec City, Canada. Available at: http://2013.colloquium.cochrane.org/abstracts/ development-quality-appraisal-tool-case-series-studies (accessed 14 August 2014). 20 Wells GA, Shea B, O’Connell D et al. The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in MetaAnalyses. Ottawa Hospital Research Institute. Available at: http:// www.ohri.ca/programs/clinical_epidemiology/oxford.asp (accessed 25 June 2014). 21 Taggart DP, D’Amico R, Altman DG. Effect of arterial revascularisation on survival: a systematic review of studies comparing bilateral and single internal mammary arteries. Lancet 2001; 358: 870–875. 22 *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– 297. 23 *De Moor RJ, De Witte AM, De Bruyne MA. Tongue piercing and associated oral and dental complications. Endod Dent Traumatol 2000; 16: 232–237.
24 *De Moor RJ, De Witte AM, Delme KI, De Bruyne MA, Hommez GM, Goyvaerts D. Dental and oral complications of lip and tongue piercings. Br Dent J 2005; 199: 506–509. 25 *Dougherty SL, Tervort-Bingham K. Assessment of the alveolar bone surrounding the mandibular anterior teeth of individuals wearing a tongue stud. J Dent Hyg 2005; 79: 8. 26 *Ebrahim R, Naidoo S. Oral and perioral piercings in Tshwane. SADJ 2008; 63: 288–291, 294, 296. 27 *Garcia-Pola MJ, Garcia-Martin JM, Varela-Centelles P, BilbaoAlonso A, Cerero-Lapiedra R, Seoane J. Oral and facial piercing: associated complications and clinical repercussion. Quintessence Int 2008; 39: 51–59. 28 *Giuca MR, Pasini M, Nastasio S, D’Ercole S, Tripodi D. Dental and periodontal complications of labial and tongue piercing. J Biol Regul Homeost Agents 2012; 26: 553–560. 29 *Kapferer I, Benesch T, Gregoric N, Ulm C, Hienz SA. Lip piercing: prevalence of associated gingival recession and contributing factors. A cross-sectional study. J Periodontal Res 2007; 42: 177–183. 30 *Kapferer I, Beier US. Lateral lower lip piercing–prevalence of associated oral complications: a split-mouth cross-sectional study. Quintessence Int 2012; 43: 747–752. 31 *Kieser JA, Thomson WM, Koopu P, Quick AN. Oral piercing and oral trauma in a New Zealand sample. Dent Traumatol 2005; 21: 254–257. 32 *Leichter JW, Monteith BD. Prevalence and risk of traumatic gingival recession following elective lip piercing. Dent Traumatol 2006; 22: 7–13. 33 *Pires IL, Cota LO, Oliveira AC, Costa JE, Costa FO. Association between periodontal condition and use of tongue piercing: a case– control study. J Clin Periodontol 2010; 37: 712–718. 34 *Vilchez-Perez MA, Fuster-Torres MA, Figueiredo R, ValmasedaCastellon E, Gay-Escoda C. Periodontal health and lateral lower lip piercings: a split-mouth cross-sectional study. J Clin Periodontol 2009; 36: 558–563. 35 Miller PD. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985; 5: 9–13. 36 Imfeld T. Dental erosion. Definition, classification and links. Eur J Oral Sci 1996; 104: 151–155. 37 Vieira EP, Ribeiro AL, Pinheiro Jde J, Alves Sde M Jr. Oral piercings: immediate and late complications. J Oral Maxillofac Surg 2011; 69: 3032–3037. 38 Des Jarlais DC, Lyles C, Crepaz N; TREND Group. Improving the reporting quality of nonrandomized evaluations of behavioral and public health interventions: the TREND statement. Am J Public Health 2004; 94: 361–366. 39 Stroup DF, Berlin JA, Morton SC et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Metaanalysis of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000; 283: 2008–2012 40 Deeks J. When can odds ratios mislead? Odds ratios should be used only in case–control studies and logistic regression analyses. BMJ 1998; 317: 1155–1156. 41 Reeves BC, Deeks JJ, Higgins JPT, Wells GA. Chapter 13: including non-randomized studies. In: Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0 [updated March 2011]. The Cochrane Collaboration; 2011. Available at: www. cochrane-handbook.org (accessed 14 August 2014). 42 Deeks JJ, Dinnes J, D’Amico R et al. Evaluating non-randomised intervention studies. Health Technol Assess 2003; 7: 1–173.
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43 Hickey BM, Schoch EA, Bigeard L, Musset AM. Complications following oral piercing. A study among 201 young adults in Strasbourg, France. Community Dent Health 2010; 27: 35–40. 44 Kapferer I, Berger K, Stuerz K, Beier US. Self-reported complications with lip and tongue piercing. Quintessence Int 2010; 41: 731–737. 45 Pearose MM, Perinpanayagam MK, ChinKit-Wells MD. Trends in oral piercing in Buffalo, New York, high schools. N Y State Dent J 2006; 72: 30–32. 46 Stead LR, Williams JV, Williams AC, Robinson CM. An investigation into the practice of tongue piercing in the South West of England. Br Dent J 2006; 200: 103–107. 47 Chrysanthakopoulos NA. Gingival recession: prevalence and risk indicators among young Greek adults. J Clin Exp Dent 2014; 6: e243–e249.
Supporting Information Additional supporting information may be found in the online version of this article.
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Appendix S1. Method of quality assessment for assessing the quality of non-randomized case–control studies. Appendix S2. Overview of the studies and reason for exclusion after full-text reading. Appendix S3. Quality assessment of case series studies using the Quality Appraisal Checklist of the Institute of Health Economics (IHE). Appendix S4. Analysis of case–control studies using the Newcastle–Ottawa Scale (NOS). Appendix S5. Overview of quality assessment of case–control studies using the Newcastle–Ottawa Scale (NOS). Appendix S6. (A) Incidence of gingival recessions in lip pierced and non-pierced groups. (B) Incidence of tooth injury in lip pierced and non-pierced groups (C) Incidence of gingival recessions in tongue pierced and non-pierced groups (D) Incidence of tooth injury in tongue pierced and non-pierced groups.
NL Hennequin-Hoenderdos DE Slot GA Van der Weijden
Authors’ affiliations: NL Hennequin-Hoenderdos, DE Slot and GA Van der Weijden, Department of Periodontology, Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, Amsterdam, The Netherlands Correspondence to: Nienke L. Hennequin-Hoenderdos Department of Periodontology Academic Centre for Dentistry Amsterdam (ACTA) University of Amsterdam and VU University Amsterdam Gustav Mahlerlaan 3004 1081 LA Amsterdam The Netherlands Tel.: + 31 (0) 20 5980 307/180 E-mail: [email protected]
The incidence of complications associated with lip and/or tongue piercings: a systematic review Abstract: Objective: This review determines the incidence of complications associated with lip and/or tongue piercings based on a systematic evaluation of the available literature. Material and Methods: MEDLINE–PubMed, Cochrane-CENTRAL and EMBASE databases were comprehensively searched through June 2014 to identify appropriate studies. The incidence of complications, as established by a dental professional associated with oral and peri-oral piercings, was evaluated in populations with lip and/or tongue piercings. The quality of the case–control studies was assessed using the Newcastle–Ottawa Scale. For case series studies, the risk of bias was assessed using the National Institute for Health and Clinical Excellence scale. Results: An independent screening of 1580 unique titles and abstracts revealed 15 publications that met the eligibility criteria. The incidence of gingival recessions appeared to be 50% in subjects with lip piercings and 44% in subjects with a tongue piercing. Tooth injuries were observed in 26% individuals with lip piercings and in up to 37% of individuals with tongue piercings. Subjects with a lip piercing were 4.14 times (P = 0.005) more likely to develop gingival recession than those without a lip piercing. Subjects with a tongue piercing were more likely than non-pierced subjects to experience gingival recession (relative risk (RR) 2.77; P = 0.00001) and tooth injuries (RR 2.44; P = 0.003). Conclusion: Both lip and tongue piercings are highly associated with the risk of gingival recession, and tongue piercings are also associated with tooth injuries. Key words: complications; incidence; lip piercing; oral piercing; systematic review; tongue piercing
Introduction Dates: Accepted 23 October 2014 To cite this article: Int J Dent Hygiene DOI: 10.1111/idh.12118 Hennequin-Hoenderdos NL, Slot DE, Van der Weijden GA. The incidence of complications associated with lip and/or tongue piercings: a systematic review. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
The practice of body ornamentation in the form of piercing was adopted by ancient civilizations and remains popular in the Western world as a manifestation of self-expression (1). Today, body piercing enjoys widespread popularity, especially among young people in Europe and North America (2). Many authors argue that tattoos and body piercings at present ‘are nothing more than fashion accessories’ (3, 4), whereas others assign them a deeper psychological meaning. Body piercing can be interpreted as a visible, self-produced violation of socially defined beauty standards and body boundaries, thereby arousing social provocation (5). Others have suggested that body modifications might enable traumatized individuals to more easily live through their personal experiences (6). Sweetman (7) claimed that the permanence and the pain involved in Int J Dent Hygiene |
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addition to the considerable amount of time required for planning and after care impart a greater value to piercing than that of simple accessories. In a study that investigated the perceptions of individuals with body piercings in relation to health behaviours and values, interviewees suggested three main reasons for body piercing: aesthetics, personal preference and fitting in with the subculture (8). Oral piercings may be placed in the lips, tongue, cheeks or uvula in various combinations. Considerable information regarding body piercing is available to adolescents through the mainstream and counterculture media, including magazines and the Internet. In particular, the Internet contains extensive information regarding body piercing, including detailed personal experiences, piercing studio listings, photos and explicit descriptions. These sources of information generally neglect to provide information on health risk factors or other health-related issues (9). The incidence of various body piercing complications varies. In one study (10) conducted in 1999, approximately 70% of the subjects with a piercing had some type of complication compared with 17% in another study (11). Intra-oral and peri-oral sites are often selected for piercing, with the tongue, lips and cheeks serving as the most commonly pierced sites. Oral piercing might begin as early as adolescence and becomes more popular in college years. Oral piercing is not harmless in that it entails local and systemic risks and has been associated with early and late complications (12). Late complications are primarily topical and include abnormal tooth wear, tooth chipping, cracking and gingival recession (13). Oral piercing is associated with serious complications as infections, abscesses and endocarditis which may cause considerable post-operative discomfort and can even be life-threatening (14). Based on a summary of the available literature, HennequinHoenderdos et al. (14) concluded that the percentage of oral and peri-oral piercings is approximately 5.2% in a young adult population (varying from 0.8% to 12%). When examined based on anatomical site, the most common sites included the tongue (a prevalence of 5.6%) followed by the lip (1.5%). Oral piercings were more prevalent in women (5.6%) than in men (1.6%) (14). Gingival recession was the most frequently described complication. Periodontitis and gingival recession were observed at the central mandibular incisors. Tooth fracture was mostly reported in subjects with tongue piercings. Subjects with tooth fractures reported a habit of knocking, clacking, biting, clenching, playing, rubbing or tapping the jewellery against their teeth. Among the case reports, reported complications included normal post-operative swelling and localized inflammation as well as more serious complications that could have been life-threatening. Moreover, in the long term, piercing may be associated with gingival recession and tooth fracture. Therefore, oral and/or peri-oral piercings are not without risks, and patients considering a piercing should be made aware of this fact (13). As one direction for further research, Hennequin-Hoenderdos et al. (14) suggested that the actual incidence of complications associated with oral and/or peri-oral piercings requires further delineation. The purpose of 2
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this review was therefore to systematically assess the literature for information concerning the incidence of complications from lip and/or tongue piercings to accurately assess the magnitude of the risk faced by individuals with these piercings. Such a study should also provide relevant information for those planning to obtain an oral or peri-oral piercing and enable dental care professionals (DCPs) to properly inform and advise the population.
Materials and methods This systematic review was conducted in accordance with the Cochrane handbook (15) for systematic reviews of interventions that provides guidance for the preparations and the guidelines of Transparent Reporting of Systematic Reviews and Meta-analyses (16). Focused question
A protocol was developed a priori for the question: What is the incidence of complications associated with oral and/or perioral (lip and/or tongue) piercings? Search strategy
The search strategy was developed with in accordance with published guidance for undertaking of systematic reviews (17). Three Internet sources were used to identify papers that satisfied the study purpose: the National Library of Medicine, Washington, DC (MEDLINE–PubMed), the Cochrane Central Register of Controlled Trials (CENTRAL) and EMBASE (Excerpta Medica Database from Elsevier). The databases were searched for studies conducted through January 2015 (Box 1). Box 1. Search terms used for MEDLINE–PubMed, CochraneCENTRAL and EMBASE. The search strategy was customized appropriately for each of the additional databases used by taking into account differences in controlled vocabulary and syntax rules. The asterisk (*) was used as a truncation symbol. {[ AND ] OR [total construct]} {[ AND ] OR [(mouth piercing*) OR (oral piercing) OR (lip piercing) OR (cheek piercing) OR (buccal piercing*) OR (tongue piercing) OR (lingual piercing*) OR (frenulum piercing) OR (uvula piercing) OR (venom piercing) OR (tooth piercing*) OR (gingiva piercing) OR (gums piercing) OR (mucosa piercing)]}
Screening and selection
Two reviewers (NLHH and GAW) independently screened the papers, first by title and then by abstract. If the information relevant to the eligibility criteria was not available in the abstract or if the title was relevant but the abstract was not available, the full text of the paper was read.
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Next, full-text papers that fulfilled the eligibility criteria were identified and included in this review. The eligibility criteria were as follows: Human subjects Cross-sectional, cohort, or case–control studies or case series Oral and/or peri-oral piercings located in the lip and/or tongue Outcomes: – Complications determined by a DCP – Incidence of complications regarding gingival recessions and/or tooth injuries – Scores by absolute numbers or percentages Papers in English or Dutch Any disagreement between the two reviewers was resolved after additional discussion. If a disagreement persisted, the judgment of a third reviewer (DES) was considered to be decisive. The two reviewers (NLHH and GAW) hand-searched the reference lists of all of the selected studies for additional published papers that could possibly meet the eligibility criteria. Papers that fulfilled all of the selection criteria were processed for data extraction. Quality assessment
The studies were judged for risk of bias by two reviewers (NLHH and DES). For case series studies, the methodological study quality was assessed using a checklist for the quality appraisal of case series studies that was developed at the Institute of Health Economics (IHE) (18, 19). The checklist consisted of 20 criteria. Each study was reviewed by answering ‘yes’, ‘partial’, ‘no’ or ‘unclear’. The maximum number of ‘yes’ responses for a study is 20 because each criterion is weighted equally. Prior to the appraisal, four criteria (9, 11, 13, 16) were considered not applicable. ‘Partial’ responses were considered ‘yes’, and ‘unclear’ was considered ‘no’ for estimating the risk of bias. A study with 0–2 ‘no’ responses was considered to have a low risk of bias, 3–5 ‘no’ responses a moderate risk, 6–8 a high risk and ≥9 a very high risk of bias. The risk of bias in case–control studies was determined using the Newcastle–Ottawa Scale (NOS) (20) for assessing the quality of non-randomized studies. This scale consists of nine items that cover three categories: the selection of the study groups; the comparability of the groups; and the ascertainment of either the exposure or the outcome of interest. The descriptions of the original NOS items were adjusted by the authors (Appendix S1) to more appropriately connect to the topic addressed in the present manuscript. This adaptation of items was previously described by Taggart et al. (21).
were extracted for a descriptive summary, and the data for both the piercees and the controls were used for the risk meta-analysis. After a preliminary evaluation of the selected papers, the data were presented in a descriptive manner. First, the number and percentage of piercees with gingival recession or a tooth injury were extracted and/or calculated per study and piercing site (tongue piercing, lip piercing or tongue and lip piercings). In addition, the weighted mean percentage for gingival recessions and tooth injuries was calculated. For the case–control studies, a risk meta-analysis was performed with relative risk (RR) as the outcome measure using Review Manager (REVMAN) Computer program (version 5.1 for Windows; The Nordic Cochrane Centre, The Cochrane Collaboration, Denmark, Copenhagen). RR values between the test and control groups were calculated using a fixed-effects model and a 95% confidence interval (CI), and P-values were calculated as well. Heterogeneity was tested using the chisquare test and the I2 statistic. A chi-square test resulting in P < 0.1 was considered an indication of significant statistical heterogeneity. As a rough guide for assessing the possible magnitude of inconsistency across studies, an I2 value of 0– 40% was interpreted as non-imperative, and moderate to considerable heterogeneity was assumed to be present for values above 40%. This quantitative analysis assessed the complications of gingival recession and tooth injury.
Results Search and selection results
The searches resulted in 1864 unique papers. After screening by title and abstract, 33 papers were selected for full-text reading, of which 18 papers were excluded because they provided no information regarding the focused question and/or did not match the eligibility criteria. Reasons for exclusion are detailed in Appendix S2. The reference lists from the selected studies were searched, but no additional papers were identified. Consequently, 15 papers were selected and processed for data extraction. A schematic overview of the search and selection results is presented in Fig. 1. Table 1 presents an overview of the selected studies. Study design
Seven studies (#04, #07, #08, #09, #11, #12, #15) were case– control studies. One (#09) of these studies applied a split-mouth evaluation in which contralateral teeth served as controls. The remaining eight studies were case series studies. No cross-sectional studies were identified.
Data analysis
Regarding the focused question, data were extracted from the selected papers by the two reviewers (DES and NLHH). For case series studies, all subjects were considered. For the case– control studies, the data on the piercees (i.e. pierced subjects)
Quality assessment
The risk of bias was assessed for case series studies using the IHE checklist for the quality appraisal of case series studies (18, 19). Quality assessment values are presented in Int J Dent Hygiene |
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Cochrane-CENTRAL
PubMed-MEDLINE
EMBASE
110
1585
473
Screening
Excluded by title and abstract 1831
Unique title & abstracts 1864
Eligibility
Identification
Hennequin-Hoenderdos et al. Incidence of complications lip/tongue piercings
Excluded after full reading 18
Selected for fulltext reading 33 Included from the reference lists 0
Experiments 15
Case-controls 7
Descriptive Analyses 15
Meta Analyses 7
Case Series 8
Analyzed
Included
Included papers 15
Tongue piercings 10
Lip piercings 9
Tongue & lip piercings 3
Tongue piercings 4
Lip piercings 4
Fig. 1. Search, selection and analysis processes.
Appendix S3. Based on these criteria, the estimated potential risk of bias was low for one study (#01), moderate for two (#13, #14), high for three (#03, #06, #10) and very high for two (#02, #05) studies. The included case–control studies were classified according to the adjusted NOS (20). Five studies (#08, #09, #11, #12, #15) were considered to have a low risk of bias; two (#04, #07) had a moderate risk, and none had a high risk of bias (Appendices S4 and S5). Heterogeneity
Twelve studies (#01, #03, #04, #07, #08, #09, #10, #11, #12, #13, #14, #15) presented information concerning their procedures for clinically assessing oral complications. Three studies (#02, #05, #06) did not provide specifications in their Materials and Methods sections. 4
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Five studies (#08, #11, #13, #14, #15) reported that all measurements were obtained by the same examiner. In one study (#04), the examination was performed by a registered dental hygienist or a dental hygiene student under the supervision of a registered dental hygienist. In Pires et al. (33; #12), all examinations were performed by two trained and calibrated examiners. Inter- and intra-examiner agreements were established by re-examinations. Campbell et al. (22; #01) noted that agreement between two examiners was required for all recordings. Controlled intra-examiner consistency was established in one study (#11) by photographic remeasurement. Eight studies (#01, #03, #07, #08, #11, #12, #14, #15) used a periodontal probe to perform the dental examination. In two studies (#08, #11), gingival recession from the cement-enamel junction (CEJ) was measured with a calibrated periodontal probe. Five studies (#07, #10, #11, #13, #14) used the Miller classification (35) for scoring gingival recession. Two studies
Campbell et al. 2002 (22)
De Moor et al. 2000 (23)
De Moor et al. 2005 (24)
Dougherty & TervortBingham 2005 (25)
Ebrahim & Naidoo 2008 (26)
Garcia-Pola et al. 2008 (27)
Giuca et al. 2012 (28)
Kapferer et al. 2007 (29)
Kapferer & Beier2012 (30)
02
03
04
05
06
07
08
09
Included studies
01
Study #
Case–control study, split-mouth
Case–control study
Case–control study
Case series
Case series
Case–control study
Case series
Case series
Case series
Study design
47 Students
50 Students
50† Patients
18◊ Patients
126† Students
23 Patients
50† Patients
15 Patients
52† Young adults
# Subjects Type of subjects
Table 1. Overview of the studies processed for data extraction Type of piercing Mean wear (SD)Range of duration of wear in months Tongue 30 (24) months 1 day–108◊ months
Tongue 13.2 months Range ? Tongue and/or lip 12.6 months Range ? Tongue 40◊ months 4◊–150◊ months Tongue and/or lip Wear ? Range ? Tongue and/or lip Wear ? Range ? Tongue and/or lip 48◊ (31◊) months Range ?
Lip 39.4 (3.5) months 3–108◊ months
Lip 37.3 (33.6) months Range ?
Gender Mean age (SD) Range in years ♂ 31 ♀ 21 22 years 18–40 years
♂ ? ♀? Age ? Range ? ♂ 13 ♀37 Age ? 12–>40 years ♂ 9 ♀14 23.4 years 18–39 years ♂ 19 ♀ 107 17.46 (1.86) years 14–24 years ♂?♀? Age ? Range ? ♂ 22 ♀ 28 T: 23.4 (3.6) years C: 24.6 (3.9) years 18–34 years ♂ 6 ♀44 21.76 (2.7) years Range ?
♂ 13 ♀ 34 20.2 (4) years Range ?
Lateral lower lip piercing is associated with significantly increased plaque accumulation on the adjacent teeth. A small percentage of lateral lower lip piercings may cause tooth chipping or buccal recession in adjacent teeth
The prevalence of gingival recession is associated with labial piercing. The position of the intra-oral disc and time since piercing are associated with a greater prevalence of buccal recession
The prevalence of abnormal tooth wear and tooth chipping was higher in the subjects with labial or lingual piercings. Moreover, patients with tongue or labial piercings exhibited a higher gingival recession compared with control subjects with no oral piercings
Buccal gingival recession is related to lower lip piercing
Long-term complications included chipping of teeth and gingival recession
Individuals wearing a tongue stud for any length of time are at risk for developing abnormalities in the alveolar bone surrounding the mandibular anterior teeth
The most common dental problem registered was chipping of teeth, especially in association with tongue piercing. Gingival recession was associated with lip piercing with studs
The most common dental problem registered was chipping of teeth. Trauma of the lingual anterior gingiva was the most common gingival problem
Tongue piercing is associated with lingual recession of the mandibular anterior teeth and chipping of the posterior teeth. Long-term use of a tongue barbell increases the prevalence of these complications
Original authors conclusions
Hennequin-Hoenderdos et al. Incidence of complications lip/tongue piercings
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Kieser et al. 2005 (31)
Leichter & Monteith 2006 (32)
Pires et al. 2010 (33)
Plessas & Pepelassi 2012 (12)
Vilchez-Perez et al. 2009 (34)
Ziebolz et al. 2012 (2)
10
11
12
13
14
15
Case–control study
Case series
Case series
Case–control study
Case–control study
Case series
Study design
46† Military subjects
50 Patients
110† Clients of tattoopiercing studios
60 Students
91 Patients
43† Patients
# Subjects Type of subjects Tongue and/or lip Wear ? Range ? Lip 11.86 (16.4) months 1–86 months
♂ 3 ♀40 21 (5) year 14–34 years ♂ 39 ♀52 25.13 (3.69) years 20–43 years ♂ 27 ♀ 33 18.9 (3.9) years Range ? Tongue and/or lip 30.3 (30.9) months 1–144 months
Lip 35.4 (19.5) months Range ?
Tongue 3.8 (3.1) months 6–118 months
♂ 52 ♀ 58 21.25 (3.55) years 18–35 years
♂ 11 ♀ 39 21.3 (4.4) years Range ?
♂ 46 ♀ 0 22.2 years 19–26 years
Tongue 25 (2.8) months 1–96 months
Type of piercing Mean wear (SD)Range of duration of wear in months
Gender Mean age (SD) Range in years
A significant correlation was revealed between tongue piercings and the increased incidence of enamel fissures, enamel fractures and gingival recession
Lateral lower lip piercings enhance gingival recession and reduce the amounts of keratinized and attached gingiva. These ornaments are also associated with tooth fractures and cracks
The prevalence of dental defects is greater for tongue versus lip piercings. Gingival recession is similar for tongue and lip piercing. Longer duration of tongue and lip piercing is associated with an increased prevalence of dental defects and gingival recession
Tongue piercings were strongly associated with gingival recession in the anterior lingual mandibular region
A clear risk exists between lip piercing, labret use and gingival recession
Oral piercings are associated with localized gingival recession
Original authors conclusions
?, No information or data presented or data extraction not possible; ◊, Calculated by the authors of this systematic review; †, Subjects with multiple piercings; T, test group; C, control group.
Included studies
Study #
Table 1. (Continued)
Hennequin-Hoenderdos et al. Incidence of complications lip/tongue piercings
Hennequin-Hoenderdos et al. Incidence of complications lip/tongue piercings
The total number of subjects varied per study from 15 to 126. The ages of study subjects varied from 12 to 43 years, with an average age of 22 years. Eight studies used patient groups (#02, #03, #04, #06, #07, #10, #11, #14). Four studies used students (#05, #08, #09, #12), and one study examined only pierced subjects (#13). One study involved military personnel (#06), and one study evaluated young adults (#01).
oping gingival recessions and tooth injuries. Tooth injuries are a rather broad description that can include tooth defects, fractures, chipping, cracks, abrasion and splitting. The focus of this systematic review was to investigate the incidence of complications as assessed by a DCP. The results based on the included papers indicate that the risk ratio for gingival recession in relation to lip piercings was 4.14. The risk ratio for developing gingival recession in relation to tongue piercings was 2.77. Furthermore, the risk ratio for tooth injuries in subjects with a tongue piercing was 2.44. In other words, subjects with lip piercings are 4.14 times more likely to develop gingival recession compared with non-pierced subjects.
Data analyses
Study design
Descriptive summaries of the incidences of complications associated with tongue piercings, lip piercings and tongue and lip piercings are presented in Tables 2–4. Seven studies (#01, #03, #05, #07, #10, #13, #15) reported that some subjects had multiple piercings. Of the 351 included subjects who had a tongue piercing, a weighted mean percentage of 42% exhibited gingival recession. On average, 37% of 426 subjects experienced a tooth injury, such as chipped/cracked/broken teeth, tooth wear or fractures (Table 2). In subjects with lip piercings, an average 43% of 411 experienced gingival recession and 24% of 280 experienced tooth injuries (Table 3). Of 40 subjects who had a tongue and a lip piercing, an average 38% exhibited gingival recession (Table 4). In all studies, complications were assessed by a DCP. Table 5 presents the risk meta-analysis results from the case–control studies using fixed-effects models. For lip piercings, the RR for gingival recessions was 4.14 with a 95% CI ranging from 1.54 to 11.13 (P = 0.005). For tongue piercings, the RR was 2.77 with a 95% CI ranging from 1.99 to 3.85 (P = 0.00001). The RR for tooth injuries in subjects with a lip piercing was 1.33 with a 95% CI ranging from 0.74 to 2.41 (P = 0.34). For tongue piercing, the tooth injury RR was 2.44 with a 95% CI ranging from 1.35 to 4.41 (P = 0.003). The numbers of subjects with and without complications in the case and control groups are presented in Appendix S6.
Over the past decades, a strong movement towards evidencebased medicine has emerged. In this context, the randomized controlled trial (RCT) is generally considered to provide the greatest evidentiary value for assessing the efficacy of interventions (38). However, the focused question of this review was answered by a review of non-randomized trials. The literature search on this topic exclusively identified observational studies. Studies that attempt to calculate a risk factor generally cannot be randomized because exposing subjects to potential harmful risk factors would be unethical (39), that is randomly exposing non-pierced patients to the risks from oral ornaments for the purpose of a study. Therefore, the literature provides quantitative (observational) studies that estimate the effects of lip and/or tongue piercings as the observed intervention without using randomization to allocate subjects to comparison groups. Inconsistent nomenclature is often used to describe non-randomized study designs (40). To be clear about the study design terminology for the studies in this review, the descriptions from the Centre for Review and Dissemination (CRD) were followed. Their Guidance for Undertaking Systematic Reviews in Health Care (2009) (17) describes case–control studies as studies that ‘compare groups from the same population with (cases) and without (controls) a specific outcome of interest, to evaluate the association between exposure to an intervention and the outcome’. Case series are ‘a description of a number of cases of an intervention and the outcome (without comparison with a control group)’ (17). Based on these definitions, five case–control studies and eight case series were included.
(#08, #10) recorded dental injuries according to the Imfeld classification (36). Number, age, range and group of subjects
Discussion This study is the third and final in a series of systematic reviews regarding oral and peri-oral piercings. The previous studies summarized the potential complications of oral and peri-oral piercings from a comprehensive collection of case reports (13) and evaluated the prevalence of oral and peri-oral piercings among young adults (14). The popularity of oral piercings results in an increased number of complications; it is necessary that professionals be prepared to encounter such situations (37). The purpose of the present review was to obtain information concerning the incidence of complications related to lip and tongue piercings. This information will help to accurately assess the magnitude of the risks associated with devel-
Potential bias and confounders
Non-randomized studies are likely to have a greater potential risk of bias than randomized studies. Therefore, the results should be interpreted with caution, and more attention must be paid to the possibility of selection bias (41). For example, the included study by Dougherty & Tervort-Bingham (25) contained exposed weaknesses. The convenience sampling was from a small geographic area; the case group was selected, and the control group was ‘pulled from existing patient records’. The sample size was small. All of the above factors serve as potential limits to generalizing the results to a larger Int J Dent Hygiene |
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Table 2. Descriptive summary of the incidence of complications from tongue piercings Gingival recession
Tooth injury
Study #
Included studies
# Subjects
Number Percentage
Number
01 02 03 04 05 07 10 12 13
Campbell et al. 2002 (22) De Moor et al. 2000 (23) De Moor et al. 2005 (24) Dougherty & Tervort-Bingham 2005 (25) Ebrahim & Naidoo 2008 (26) Giuca et al. 2012 (28) Kieser et al. 2005 (31) Pires et al. 2010 (33) Plessas & Pepelassi 2012 (12)
52 15 47 22 100 25 33 60 51*
10 6 4 9 ? 5 14 48 24
19.2 40◊ 8.5◊ 40.9◊ ? 20◊ 42.4 80 47◊
10 12 25 8 13 ? 11 16 24
19.2◊ 80◊ 53.2◊ 36.4◊ 13◊ ? 33.3 26.7 47◊
15
Ziebolz et al. 2012 (2)
46
27
58.7
38
82.2
Total gingival recession Total tooth injury
351 426
Percentage
Description Chipped teeth Chipped teeth Chipped teeth Broken teeth Chipped teeth ? Worn incisors Fracture Worn, chipped and cracked teeth Cracked teeth
x 41.8◊ x 36.8◊
?, No information or data presented or data extraction not possible; ◊, Calculated by the authors of this systematic review; *, number of piercings.
Table 3. Descriptive summary of the incidence of complications from lip piercings Gingival recession
Tooth injury
Study #
Included studies
# Subjects
Number
Percentage
Number
03 06 07 08 09 10 11 13 14
De Moor et al. 2005 (24) Garcia-Pola et al. 2008 (27) Giuca et al. 2012 (28) Kapferer et al. 2007 (29) Kapferer & Beier 2012 (30) Kieser et al. 2005 (31) Leichter & Monteith 2006 (32) Plessas & Pepelassi 2012 (12) Vilchez-Perez et al. 2009 (34)
8 15 25 50 47 15 91 110* 50
5 5 2 34 4 14 62 40 11
62.5 33.3◊ 8◊ 68 8.5◊ 93.3 68.1◊ 36.4◊ 22
2 ? ? 18◊ 7◊ 3 ? 28 10
Total gingival recession Total tooth injury
411 280
Percentage 25 ? ? 36◊ 14.9◊ 20 ? 25.5◊ 20
Description Chipped teeth ? ? Chipped and cracked teeth Tooth chipping and cracks Worn incisors ? Worn, chipped and cracked teeth Fractured and cracked teeth
x 43◊ x 24.3◊
?, No information or data presented or data extraction not possible; ◊, Calculated by the authors of this systematic review; *, number of piercings.
Table 4. Descriptive summary of the incidence of complications from tongue and lip piercings Gingival recession
Tooth injury
Study #
Included studies
# Subjects
Number
Percentage
Number
Percentage
Description
05 07 10
Ebrahim & Naidoo 2008 (26) Giuca et al. 2012 (28) Kieser et al. 2005 (31)
10 25 5
2 8 5
20◊ 32◊ 100
? 2
? 40
? Worn incisors
Total gingival recession
40
x 37.5◊
?, No information or data presented or data extraction not possible; ◊, Calculated by the authors of this systematic review.
population. Additionally, multiple oral health care providers collected the data, and some variables were not clearly defined. Again, all of these factors could have resulted in bias. Estimating potential confounders illustrates the extent of heterogeneity between studies. Complications, such as gingival 8
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recession, may be caused by oral or peri-oral piercings, but the observed complication may also have another origin. In the literature, several authors considered other factors as causes of gingival recession, such as plaque-induced inflammation, toothbrush trauma, tooth alignment, orthodontic treatment, restor-
Hennequin-Hoenderdos et al. Incidence of complications lip/tongue piercings
Table 5. Risk meta-analyses of case–control studies using fixed-effects models Heterogeneity Model 95% CI
P-value
I2 (%)
P-value
4.14
1.54; 11.13
0.005
59
0.06
Fixed
1.33
0.74; 2.41
0.34
0
0.47
Dougherty & Tervort-Bingham 2005 (25) Giuca et al. 2012 (28) Pires et al. 2010 (33) Ziebolz et al. 2012 (2)
Random
2.77
1.99; 3.85
0.00001
14
0.32
Dougherty & Tervort-Bingham 2005 (25) Pires et al. 2010 (33) Ziebolz et al. 2012 (2)
Fixed
2.44
1.35; 4.41
0.003
0
0.70
Site
Complication
# Study
Included studies
Lip piercing
Gingival recession
07 08 09 11
Giuca et al. 2012 (28) Kapferer et al. 2007 (29) Kapferer & Beier 2012 (30) Leichter & Monteith 2006 (32)
Random
Tooth injury
08 09
Kapferer et al. 2007 (29) Kapferer & Beier 2012 (30)
Gingival recession
04 07 12 15
Tooth injury
04 12 15
Tongue piercing
CI, confidence Interval.
ative procedures, smoking status (29), calculus, poorly designed or poor-fitting partial dentures, fixed partial dentures, high lingual frenum (25), periodontal biotype (12, 29), height of keratinized gingiva (34) and oral health and hygiene status (2). Campbell et al. (22) measured some of the factors and reinforced the likely contribution of the mechanical action of the tongue barbell to the observed gingival damage, presumably during tongue protrusion. However, possible confounding factors, such as age, gender, duration of wear, sort/type of piercing, length/size of the piercing, location of the piercing, position of the piercing (i.e. angle; whether it protrudes from or is submerged under the soft tissue), piercing material, previous trauma, participation in contact sports and behaviour of the person in moving the piercing, could be relevant for the interpretation of this review. These data are lacking in the case–control studies. Risk meta-analysis and quality assessment
In this review, risk meta-analyses were performed to systematically combine the results of the included case–control studies to obtain a combined estimated effect. The RR was calculated, representing the ratio of the probability of an event’s occurring in the exposed group to the probability of the same event’s occurring in a non-exposed group. Risk meta-analyses of observational studies present particular challenges given the inherent biases and differences in study designs. However, these studies may help to understand the results and quality sources of variability across studies (39). Guidelines for reporting the risk meta-analysis results from observational studies (39) recommend that the ‘assessment of confounding factors, study quality and heterogeneity’ be clearly reported. The results of the quality assessment in this review were used to highlight items of methodological quality and heterogeneity that were addressed by the included studies. Many instru-
ments for assessing the methodological quality of non-randomized intervention studies have been created and were reviewed systematically by Deeks et al. (42). The Newcastle– Ottawa Scale (20) was developed to assess the quality of nonrandomized studies with its design, content and ease of use directed to the task of incorporating the quality assessments in the interpretation of risk meta-analysis results. A star system is used to allow for the visual, semi-quantitative assessment of study quality (42). Appendix S5 indicates the scale allowed for discrimination between case–control studies with respect to quality. The risk meta-analysis for gingival recession included low- to high-quality studies, whereas the quality in relation to tooth injuries was higher. Risk meta-analysis using the chisquare test revealed that heterogeneity was not significant in those studies that reported on tooth injuries. In the studies that reported on gingival recession, the I2 varied from 14% to 52%, which can be interpreted as minor to moderate heterogeneity. Questionnaires
Differences in research methodology (questionnaires versus clinical examination) were reflected in the different incidences of complications. The information about the variables that was presented in the selected studies was collected through clinical examination. Gingival recession reported on a questionnaire is subject to the underestimation of current conditions. Therefore, this review exclusively included studies for which complications were assessed by a DCP. Self-assessment questionnaires on non-painful gingival or dental trauma are of limited value because such damage often goes unnoticed by patients due to lack of dysfunction (29). Four studies (43–46) that were not included in this review evaluated piercees’ perceptions of the risk of complications from oral and peri-oral piercings. The results of the surveys were widespread, and it Int J Dent Hygiene |
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Hennequin-Hoenderdos et al. Incidence of complications lip/tongue piercings
can be assumed that this is a reflection of the fact that questionnaires were used. Tooth injuries were reported in 3% (44) to 41% (45) of subjects, and gingival recession reporting ranged from 2% (45) to 42% (44); the values for both conditions were dependent on the piercing location. Another recently published study (47) assessed the prevalence of gingival recession among young Greek adults in a sample of 1430 subjects. In this study, the prevalence of gingival recession was found to be 63.9% as assessed by clinical examination by a periodontist. The prevalence of oral piercings was 8% as established based on a questionnaire. The authors found a weak but positive association between the occurrence of gingival recession and the presence of oral piercing. They concluded that oral piercing is a cultural-causative associating factor for gingival recession (47).
informed that the longer the duration of wear, the greater the chance that oral complications will develop. In addition, patients should be advised that piercings increase the possibility of developing dental defects and gingival recession. It is also recommended that questions regarding (former) piercings and their complications be included in medical and dental questionnaires. Practical limitation
When patients remove their lip or tongue piercings before dental examination, the DCP is unaware of the fact that these piercings could be the reason for the observed oral complications. Lip and tongue piercings as aetiological factors should be considered in the differential diagnosis of gingival recession and tooth injuries, especially in young adults.
Conclusions Within the limitations of this study, the following conclusions can be drawn. The frequency of post-piercing complications depends on piercing location in relation to the oral cavity. Piercing may cause tooth chipping or cracks as well as buccal recession in the teeth that are in direct contact with the stud closure. A significant relative risk was revealed between tongue piercings and an increased incidence of enamel fissures, enamel fractures and gingival recessions (especially in the lingual region of the mandibular incisors). Both lip and tongue piercings were highly associated with gingival recession. From the dental perspective, the popularity of oral and peri-oral piercings is a cause for concern in light of the number of oral complications and risks.
Clinical relevance Scientific rationale for the study
Gingival recessions are frequently described as a complication associated with lip or tongue piercings, and tooth fractures are reported as a complication for tongue piercings. The incidence of these complications associated with lip and tongue piercings is unknown. Principle findings
Lip and tongue piercings are highly associated with the risk of gingival recession and tooth injuries. Practical implications
Lip and tongue piercings are not without risks. Dental care professionals (DCPs) should be aware of the risks to properly inform and advise the target population. It is best to discourage oral piercings and improve awareness of the complications associated with oral piercings. Patients with these piercings should be screened by a DCP for possible dental or periodontal complications on a regular basis. The patient should be 10
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Acknowledgements The authors thank the Ivoren Kruis (Ivory Cross, the Dutch society for the promotion of dental and oral health) for initiating and partly sponsoring this project. The authors also acknowledge the support of Joost Bouwman, head librarian of the ACTA, who helped retrieve the full-text papers.
Conflict of interest The authors declare that they have no conflict of interests.
Source of funding The preparation of this review was self-funded by the authors and their institutions and supported by a seed grant from the Dutch organization that promotes oral and dental health (Ivory Cross).
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Supporting Information Additional supporting information may be found in the online version of this article.
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| Int J Dent Hygiene
Appendix S1. Method of quality assessment for assessing the quality of non-randomized case–control studies. Appendix S2. Overview of the studies and reason for exclusion after full-text reading. Appendix S3. Quality assessment of case series studies using the Quality Appraisal Checklist of the Institute of Health Economics (IHE). Appendix S4. Analysis of case–control studies using the Newcastle–Ottawa Scale (NOS). Appendix S5. Overview of quality assessment of case–control studies using the Newcastle–Ottawa Scale (NOS). Appendix S6. (A) Incidence of gingival recessions in lip pierced and non-pierced groups. (B) Incidence of tooth injury in lip pierced and non-pierced groups (C) Incidence of gingival recessions in tongue pierced and non-pierced groups (D) Incidence of tooth injury in tongue pierced and non-pierced groups.
