Continuing Education
Course Number: 113.1
Bone Loss Associated With
the Use of Tongue Piercing:
Case Report
Authored by Camila Stadiniski Gonçalves, DDS, Marcelo de Faveri, DDS, MS, PhD,
Mitsue F. Hayacibara, DDS, MS, PhD, Osvaldo Magro Filho, DDS, MS, PhD and
Roberto M. Hayacibara, DDS, MS
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Continuing Education
Recommendations for Fluoride Varnish Use in Caries Management
Bone Loss Associated With
the Use of Tongue Piercing:
INTRODUCTION
The popularity of wearing body adornments in
unconventional places, such as the navel, nipples,
eyebrow, lips, and tongue has grown significantly, thus
contributing to reports of complications associated with this
practice. Inserting metal objects in intraoral sites has
become a common practice.1,2 The perforations are usually
made in the tongue and lips 3,4, the tongue being the most
frequent location,5,6 and they are usually placed anterior to
the lingual frenum.1,5,7-9 The first case reported in the
literature involving the use of tongue piercing was
described by Scully and Chen8 in 1998. Thereafter, other
reports in the scientific literature have recorded different
complications that involve this body culture practice.3,5,7,10
The most common consequences associated with the
use of tongue piercing are pain, swelling, and
infection.3,7,8,11 In addition, there may be damage to perioral
structures, compromised airway because of aspirating the
device, and edema8,9; interference with speech,
mastication, and deglutition3,7-9,11; Ludwig’s angina10;
hypersensitivity to the metal7,9; obstruction in radiographic
images7; galvanic current1; and hemorrhage due to the
vascularity of the tongue and probability of blood vessel
perforation.1,7 Intraoral structural damage can also occur,
such as tooth chipping,1,5,6,9,11,12 gingival recession,1,2,5,11,13,14
and pulpal damage caused by chronic trauma.1,5,9,14
Most of the scientific studies that describe the
complications of tongue piercing refer particularly to dental
structure damage,1,5,6,9 but few articles have pointed out
other damage in the oral cavity. Panagakos, et al13 and
Kretchmer and Moriarty2 reported the first cases of loss of
periodontal attachment related to the use of tongue
piercing. However, there are few articles in the literature
that refer to periodontal damage such as gingival recession
and bone loss as a consequence of the use of tongue
piercing, even with no gingival inflammation caused by
dental biofilm. This paper reports a clinical case of tongue
piercing which resulted in gingival recession and bone loss
at the site of the mandibular central incisors.
Case Report
LEARNING OBJECTIVES:
After reading this article, the individual will learn:
•
•
Complications of tongue piercing.
Diagnosis and treatment of bone loss caused by
tongue piercing.
ABOUT THE AUTHORS
Dr. Gonçalves is in private practice in
Maringá, PR, Brazil. She can be reached
at [email protected].
Dr. Faveri is adjunct professor, Department of Periodontology,
Dental Research Division, Guarulhos University, Guarulhos,
SP, Brazil. He can be reached at [email protected].
Dr. Mitsue F. Hayacibara is adjunct professor, Department of
Dentistry, State University of Maringá, Maringá, PR, Brazil.
She can be reached at [email protected].
Dr. Magro-Filho is adjunct professor, Department of Surgery
and Integrated Clinic, São Paulo State University “Júlio de
Mesquita Filho,” Araçatuba, SP, Brazil. He can be reached at
[email protected].
Dr. Roberto M. Hayacibara is assistant professor,
Department of Dentistry, State University of Maringá, Maringá,
PR, Brazil. He can be reached via e-mail at
[email protected].
CASE REPORT
Disclosure: The authors report no conflict of interest.
The patient was an 18-year-old leukodermal man who
1
Continuing Education
Bone Loss Associated With the Use of Tongue Piercing: Case Report
had been wearing an orthodontic appliance for 36 months.
During routine consultation it was observed that there was
a loss of papilla involving teeth Nos. 24 and 25 (Figure 1).
The patient was referred to the Periodontal Unit of the State
University of Maringá (Brazil), where an intraoral
examination showed that the site of the lingual mucosa
membrane of the mandibular incisors was swollen and
there was lingual gingival recession between teeth Nos. 24
and 25 (Figure 2). Periodontal examination revealed good
oral hygiene (oral hygiene index of 22%15) and no other
tooth presented any type of periodontal alteration.
A barbell-shaped tongue piercing perforating the
midline of the tongue was detected (Figure 3). The inferior
ball of the piercing was in close contact with the swollen
area and the mandibular central incisors (Figure 4). The
patient reported that he had been wearing the jewelry for
approximately 2 years.
In the radiographic exam, bone loss of 5 mm between
the mandibular central incisors was observed, involving
more than half of the bone support, with characteristics of
trauma, such as widening of the periodontal ligament and
loss of integrity of the duralamina (Figure 5). The
pretreatment orthodontic records showed no alteration in
the bone support at the site of the mandibular central
incisors (Figure 6).
The proposed treatment was to remove the piercing
and to follow up the case. A 3-month radiographic follow-up
of the site after the piercing was removed showed absence
of edema (Figure 7) and complete bone regeneration of the
area at the lingual site between the mandibular central
incisors (Figure 8). 8
Figure 1.
Loss of papilla
involving teeth Nos.
24 and 25.
Figure 2.
Lingual gingival
recession between
teeth Nos. 24 and 25;
the site of the lingual
mucous membrane of
the mandibular
incisors was swollen.
Figure 3.
Tongue piercing
through
the tongue,
approximately
20 mm long.
Figure 4.
Tongue piercing
through the tongue in
close contact with
both the area
presenting edemas
and the inferior
mandibular central
incisors.
DISCUSSION
healing period 7 to accommodate the swelling of the tongue
that usually occurs in the first few days.3 Approximately 2
weeks after the perforation, the 18 mm temporary piercing
is replaced by the permanent metal piercing 3 which can
vary in length.
There are numerous consequences related to this
practice. Among them, 2 concerning damage in the oral
cavity have repeatedly been mentioned in the literature:
tooth chipping1,5,6,9 and gingival recession.1,2,5,13 Tooth
Body piercing has become increasingly fashionable
over the years, especially among young adults.5 The
intraoral sites may involve lips, cheeks, tongue, and uvula.3
The tongue is the most commonly pierced intraoral site,6
and the perforation is usually made in the midline, in a
ventral dorsum or dorsum ventral direction, and anterior to
the lingual frenum.6 The procedure is usually performed
without anesthesia 9 and in 2 stages.3,7 A temporary plastic
stem, larger than the permanent one, is inserted during the
2
Continuing Education
Bone Loss Associated With the Use of Tongue Piercing: Case Report
chipping occurs mainly in the molars and premolars (61%
and 31%, respectively) and 88% of the gingival recessions
are present in the mandibular central incisors.5
In this case report the patient presented with buccallingual gingival recession at the site of the mandibular
central incisors. The etiological factors related to gingival
recession can be attributed to attachment loss due to
periodontitis,16,17 presence of calculus,18 and a high lingual
frenum.19 In addition, abrasion from toothpastes, excessive
pressure when brushing, and horizontal movements of the
brush could contribute to gingival injuries.20 However, as
the patient presented with good oral hygiene, no gingival
inflammation caused by dental biofilm, and a high lingual
frenum, some of the possible causes of the recession were
excluded. Abrasion from toothpastes and tooth brushing
trauma were also excluded, since the recessions were
restricted to 2 teeth, mainly at the lingual face. The other
areas of the periodontium did not present with any disorder.
The constant trauma caused by the tongue piercing during
the tongue protrusion movements on the mandibular
central incisors, associated with the significant size of the
ball attached to the end of the metal piercing stem, were
clearly indicated as the etiological factor of the problem.4,14
Gingival recession appears to be related to time of use
and length of the piercing stem, with 15.9 mm or longer
stems being associated with recessions, and shorter stems
with tooth chipping.5 These 2 factors probably compounded
the damage, considering the length of the piercing stem
(20 mm) and the period of its use (2 years) (Figure 5).
In this clinical case, the radiographic exam showed a
horizontal bone loss of 5 mm between the mandibular
central incisors. In agreement with current research, the
possible factors related to bone resorption that occurs in
the dental support tissues are an inflammatory lesion
associated with dental plaque21 and/or occlusal trauma.22,23
Considering that intraoral examination of this patient did not
reveal periodontal pocketing or bleeding on probing, the
possibility of an inflammatory lesion associated with dental
plaque was excluded. A clear explanation for such bone
resorption and gingival recession was the presence of the
piercing, a traumatic factor which probably caused the
lesion to develop. This could be verified, as removal of the
tongue piercing itself promoted regeneration of the
Figure 5.
Periapical radiograph.
Bone loss in the
mandibular central
incisors area.
Increase in
periodontal thickening
and discontinuity in
the dental lamina.
Figure 6.
The pretreatment
orthodontic records
without alteration in
the bone support at
the site of the
mandibular central
incisors.
Figure 7.
Absence of edema
at the inferior site
after removing
the piercing.
Figure 8.
Periapical radiograph.
Bone regeneration in
the lingual area of the
inferior incisors,
accentuated after
removal of the
tongue piercing.
3
Continuing Education
Bone Loss Associated With the Use of Tongue Piercing: Case Report
REFERENCES
traumatized area. According to Panagakos, et al,13 who first
described a case of loss of periodontal attachment related
to a tongue piercing, the constant pressure applied in the
area during functioning and as part of a parafunctional
habit, along with gingival inflammation, led to the
development of a severe loss of attachment. Kretchmer
and Moriarty 2 also reported a situation in which the gingiva
and alveolar bone were reduced because of the
inflammation caused by dental biofilm associated with the
constant trauma caused by a piercing. When compared
with occlusion trauma, piercing trauma alone can lead to
bone loss, but it cannot cause loss of periodontal
attachment. When associated with dental plaque, trauma
can increase the speed of periodontal disease progression,
acting as a co-factor in the destructive process.24
Therefore, Choe, et al 11 agreed that tongue piercing can be
a periodontal risk factor.12
Another important aspect to consider in this case is the
possibility that the trauma caused by the piercing could
result in an oral pathologic tooth migration of the central
incisors, as a reaction to the aggression. As the alveolar
bone is usually remodeled to adapt to functional changes,
this situation could have occurred if the patient had not
worn an orthodontic appliance. Thus, it is likely that the
orthodontic appliance acted to contain the trauma, and the
bone reacted through a pathological resorption.
When such devices are seen by clinicians, they should be
removed or the patient should be advised of the risk of
retaining such a device. If the patient declines to have it
removed, he/she should sign a release form to be added to the
chart stating: “I have been been advised of the risks of having
an oral device in my mouth, decline to have the oral device
removed, and accept all risks associated with retaining it.”
1. De Moor RJ, De Witte AM, De Bruyne MA. Tongue piercing
and associated oral and dental complications. Endod Dent
Traumatol. 2000; 16:232-237.
2. Kretchmer MC, Moriarty JD. Metal piercing through the
tongue and localized loss of attachment: a case report.
J Periodontol. 2001;72:831-833.
3. Farah CS, Harmon DM. Tongue piercing: case report and
review of current practice. Aust Dent J. 1998;43:387-389.
4. Zadik Y, Sandler V. Periodontal attachment loss due to
applying force by tongue piercing. J Calif Dent Assoc.
2007;35:550-553.
5. Campbell A, Moore A, Williams E, et al. Tongue piercing:
impact of time and barbell stem length on lingual gingival
recession and tooth chipping. J Periodontol. 2002;73:289-297.
6. Bassiouny MA, Deem LP, Deem TE. Tongue piercing: a
restorative perspective. Quintessence Int. 2001;32:477-481.
7. Price SS, Lewis MW. Body piercing involving oral sites.
J Am Dent Assoc. 1997;128:1017-1020.
8. Scully C, Chen M. Tongue piercing (oral body art). Br J Oral
Maxillofac Surg. 1994;32:37-38.
9. Reichl RB, Dailey JC. Intraoral body-piercing: a case report.
Gen Dent. 1996;44:346-347.
10. Perkins CS, Meisner J, Harrison JM. A complication of
tongue piercing. Br Dent J. 1997;182:147-148.
11. Choe J, Almas K, Schoor R. Tongue piercing as risk factor to
periodontal health. NY State Dent J. 2005;71:40-43.
12. De Moor RJ, De Witte AM, Delmé KI, et al. Dental and oral
complications of lip and tongue piercings. Br Dent J.
2005;199:506-509.
13. Panagakos FS, Linfante J, Pascuzzi JN. Attachment loss
associated with the presence of a tongue bar: a case report.
Gen Dent. 2000;48:454-456.
14. Levin L. Alveolar bone loss and gingival recession due to lip
and tongue piercing. NY State Dent J. 2007;73:48-50.
15. Lindhe J, Okamoto H, Yoneyama T, et al. Longitudinal
changes in periodontal disease in untreated subjects.
J Clin Periodontol. 1989;16:662-670.
CONCLUSION
16. Löe H, Anerud A, Boysen H. The natural history of
periodontal disease in man: prevalence, severity, and extent
of gingival recession. J Periodontol. 1992;63:489-495.
Under certain circumstances, the extensive use of
tongue piercing can lead to bone loss and gingival
recession in the area of the mandibular central incisors.
17. Yoneyama T, Okamoto H, Lindhe J, et al. Probing depth,
attachment loss and gingival recession. Findings from a
clinical examination in Ushiku, Japan. J Clin Periodontol.
1988;15:581-591.
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Continuing Education
Bone Loss Associated With the Use of Tongue Piercing: Case Report
18. van Palenstein Helderman WH, Lembariti BS, van der
Weijden GA, et al. Gingival recession and its association
with calculus in subjects deprived of prophylactic dental
care. J Clin Periodontol. 1998;25:106-111.
22. Lindhe J, Ericsson I. The effect of elimination of jiggling
forces on periodontally exposed teeth in the dog.
J Periodontol. 1982;53:562-567.
19. Ewart NP. A lingual mucogingival problem associated with
ankyloglossia: a case report. NZ Dent J. 1990;86:16-17.
23. Lindhe J, Svanberg G. Influences of trauma from occlusion
on progression of experimental periodontitis in the beagle
dog. J Clin Periodontol. 1974;1:3-14.
20. Holmstrup P, van Steenbergue D. Non-plaque induced
inflammatory gingival lesions. In: Lindhe J, Karring T, Lang
NP, eds. Clinical Periodontology and Implant Dentistry. 4th
ed. Oxford, England: Blackwell Munksgaard; 2003:289.
24. Lindhe J, Nyman S, Ericsson I. Trauma from occlusion. In:
Lindhe J, Karring T, Lang NP, eds. Clinical Periodontology
and Implant Dentistry. 4th ed. Oxford, England: Blackwell
Munksgaard; 2003:352.
21. Kinane DF, Berglundh T, Lindhe J. Host-parasite interactions
in periodontal disease. In: Lindhe J, Karring T, Lang NP,
eds. Clinical Periodontology and Implant Dentistry. 4th ed.
Oxford, England: Blackwell Munksgaard; 2003:150.
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Continuing Education
Bone Loss Associated With the Use of Tongue Piercing: Case Report
3. In tongue piercing, the perforation is usually made:
a. in the midline.
b. in a ventral-dorsum or dorsum-ventral direction.
c. anterior to the lingual frenum.
d. all of the above.
POST EXAMINATION INFORMATION
To receive continuing education credit for participation in
this educational activity you must complete the program
post examination and receive a score of 70% or better.
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completion” will be mailed to the address provided.
4. The tongue piercing procedure is usually
performed without anesthesia. The procedure is
usually performed in 3 stages.
a. First statement is false, second is true
b. First statement is true, second is false
c. Both statements are false
d. Both statements are true
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5. With tongue piercing _____ % of tooth chipping
occurs in the molars.
a. 31
b. 42
c. 61
d. 75
6. _____% of the gingival recessions associated with
tongue piercing are present in the mandibular
central incisors.
a. Thirty-one (31)
b. Sixty-one (61)
c. Seventy-five (75)
d. Eighty-eight (88)
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7. Metal stems 15.9 mm or longer are associated
with gingival recessions. Shorter stems are
associated with tooth chipping.
a. First statement is false, second is true
b. First statement is true, second is false
c. Both statements are false
d. Both statements are true
POST EXAMINATION QUESTIONS
1. The most frequent intraoral site for inserting metal
objects is:
a. lips.
b. cheeks.
c. tongue.
d. uvula.
8. When compared with occlusion trauma piercing
trauma can lead to bone loss. When associated
with dental plaque, piercing trauma can increase
the speed of periodontal disease progression.
a. First statement is false, second is true
b. First statement is true, second is false
c. Both statements are false
d. Both statements are true
2. The most common consequence(s) associated
with tongue piercing is/are:
a. pain.
b. swelling.
c. infection.
d. all of the above.
6
Continuing Education
Bone Loss Associated With the Use of Tongue Piercing: Case Report
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